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Oregon Department of Environmental Quality <br /> 1. General System Information <br /> The Existing System Evaluation Report form contains 8 pages.Some of the questions on this <br /> form may not pertain to they system being evaluated,as there are many systems designs. If you(the <br /> septic system evaluator)are unable to answer any of the questions on this form please indicate,in <br /> writing,why this information was not available at the time the evaluation was completed. <br /> * The existing septic system consists of(check all that apply): <br /> x iSeptic Tank j Cesspool <br /> {x!Dosing Tank x I Disposal Trenches/Leach Lines <br /> ( )-(1 Multi-compartment Tank [ 1 Capping Fill <br /> L ISeepage Bed. F j Sand Filter <br /> Other(please describe) <br /> Note:Cesspools may be used only to serve existing sewage loads and if failing only be replaced with <br /> a seepage pit system on lots that are too small to accommodate a standard system or other alternative <br /> onsite system. <br /> * There is a permit for the septic system ! Yes [-xi No Unknown <br /> * Permit Number(s) <br /> * Year original septic system installed: (YYYY) I`xi No record of installation date <br /> * Dates of subsequent repairs or alterations: (YYYY) <br /> * All plumbing fixtures are connected to the septic system `Yes L I No x I Unknown <br /> If you answered"No,"or"unknown,"please describe below: <br /> NO HOUSE ON PROPERTY DUE TO WILDFIRE. <br /> * Additional Comments: <br /> MIKE STATES THAT SEPTIC TANK WAS INSTALLED IN 1998. <br /> 2. Overall Septic System Status <br /> Discharge of sewage to theground surface I r_.._I <br /> * g g � �Yes 1 �No i x None observed <br /> * Discharge of sewage to surface waters { I Yes L i No L xi None observed <br /> * Sewage backup into plumbing fixtures 1 Yes El No rx__;Unknown <br /> * Additional Comments: <br /> NO HOUSE ON PROPERTY DUE TO WILDFIRE. <br /> 3. Septic tank <br /> In order to fully describe the condition of the tank,the septic tank may need to be pumped. Please indicate <br /> below if the septic system tank was pumped during the course of this evaluation. <br /> r-- <br /> * Septic tank was pumped during the course of this evaluation ; x 1 Yes G ;No <br /> * If the septic tank was NOT pumped during the course of this evaluation, please explain (e.g. <br /> septic system owner declined to have the tank pumped etc): <br /> Page 2 of 8 <br />