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Oregon Department of Environmental Quality <br /> • Dosing tank capacity (gallons) <br /> • Tank volume determined by: Check all that apply,add comments below as needed <br /> ❑Permit Records❑Measured❑ Stamped on Tank❑Other <br /> • Dosing tank material <br /> • Dosing tank appears to be watertight and in good condition ['Yes ❑No <br /> • Dosing tank lid is intact ❑Yes ❑No <br /> • Electrical components are sealed and watertight ❑Yes No <br /> • Pump/siphon is functional ['Yes ❑No <br /> • Type of Pump ❑Demand dose ['Time dose <br /> • Pump control mechanism is functional(floats,pressure transducer)['Yes ['No <br /> • There is a high water alarm['Yes ONO <br /> • The high water alarm(audible and visual)is working ❑Yes ❑No ['Not Applicable <br /> • Type of screen <br /> • Screen is clean and free of debris['Yes ❑No-Screen cleaned for this evaluation[Nes ❑No <br /> • Scum/sludge present in Dosing tank ['Yes ['No <br /> • Scum layer (inches) Sludge layer (inches) <br /> • Additional Comments: <br /> 5. Soil absorption system <br /> The soil absorption system is a set of trenches that receives effluent from the septic tank and <br /> filters the effluent before it enters the groundwater. <br /> • The septic system has a soil absorption systemgYes ❑No ['Unknown <br /> • Was the soil absorption system part of the evaluation?['Yes inNo ['See note below <br /> If the soil absorption system was not evaluated,please explain below(for example unable to <br /> locate,c ien .i. not authorize this .art of the evaluation : <br /> %e7 alt-4-41. --La, I II f- di'aL'(. 0 <br /> • Absorption distribution ❑Equal ❑Serial ❑Pressure ❑Equal via pressure <br /> • Absorption lines construction material: <br /> ❑ Gravel and pipe ❑Chamber ❑Tile ❑Polystyrene foam and pipe ❑Other <br /> • Absorption distribution unit(s): ndropbox❑hydrosplitter❑equal distribution box <br /> ❑Intact ❑Damaged ❑N/A <br /> • Absorption distribution unit(s)are free of debris or solids ❑Yes ❑No ❑N/A <br /> Page 4 of 8 <br />