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64-0-61c-5-1(0 <br /> RECEIVED. <br /> Existing System Evaluation Report for Onsite SEP 2 5 2024 <br /> DE Wastewater Systems <br /> DE State of Oregon Department of Environmental Quality <br /> State of Oregon <br /> Deportment m Onsite Program <br /> 165 East Seventh Ave, Suite 100 <br /> ouarity <br /> Eugene, OR 97401 <br /> Please answer the following questions completely. Do not leave any blank responses.Write unknown if <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information,and please visit <br /> http://www.oreaon.gov/dea/Residential/Pages/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: II <br /> Property Owner(s)(Sellers): J%4kith - 4-1- - 2),Y.:ich, Telephone: c03-S$t-7/2)1 <br /> Site Address: 7644 Champion Hill Rd City: Salem Zip Code:97306 <br /> County: Marion Lot Size: ? Ae_Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system (years) Is there a service contract for system components? <br /> Date the septic tank was last pumped _ _2 lease attach receipt if available) <br /> Number of people occupying dwelling 2_ If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? <br /> The above information is true and to the best of my knowledge. <br /> o7- /8 - z©zy <br /> Date(MM/DD/YYYY) Signature of Owner,or ag if present <br /> Name of person performing evaluation(please print): <br /> Certification: • <br /> ❑✓ Installer ❑ Professional Engineer <br /> ❑ Maintenance Provider 0 Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification-Number: RI 925 <br /> Business name Carl's Septic LLC Email eric.carlsseptic@gmail.com <br /> Business address 4742#147 S Liberty Rd, Salem, OR, 97302 Phone 503.910.6329 <br /> Date of Evaluation: 9/18/24 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> 9/18/24 [Digitally Signed Eric Zade] <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />