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i4 :t ExistingSyste i Eva k tion Rep.rt for Onsite 3astew iter Systems - ' State of Oregon Department of Environmental Quality Deparenent State m Onsite Program ;s Q 185 East Seventh Ave, Suite 100 z Eugene, OR 97401 - ,t,.->, Please answer the following questions completely. Do not leave any blank responses.Write unknown if unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please visit:http://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx Septic System Owner-Provided Information: Property Owner(s)(Sellers): nc y 5VA\ Six, -v_i Telephone: Cw , Site Address: t 1 Au�I t?� City: Si. M-flit Y4 Zip Code: C‘1 J 7 Acres/Square Feet(circle units) f\'��`�� Lot Size: � ‘ � 9 Legal Description: CG-_.1 L.,01 l) a)gam; Age of wastewater treatment system v /4,14 ears) Is there a service contract for system components? Y W Date the septic tank was last pumped t,'ikv}o.sIplease attach receipt if available) a Number of people occupying dwelling If unoccupied,for how long has it been vacant? . -. > `+- Was this section completed by the evaluator because owner or agent was unavailable? ty75 The above information is true and to the best of my knowledge. Date(MM/DD/YYYY) Signature of Owner,or agent if present Name of person performing evaluation(please print): Nick Homutoff Certification: ❑ Installer ❑ Professional Engineer ❑✓ Maintenance Provider ❑ Environmental Health Specialist ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist ❑ Other:DEQ approved in writing(please describe) Certification Number: RM 41 Business name Farmers Septic Company Email farmerssepticco@aol.com Business address 15127 Evans Valley Rd NE, Silverton OR 97381 Phone 503-873-3344 „0 x Date of Evaluation: i. 1.L - I (MM/DD/YYYY) I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater system evaluations in the state of Oregon pursuant to OAR 340-071-0155. Date(MM/DD/YYYY) Signature of Qualifie I '.Attic System Evaluator t, Page 1 of 8 Updated 12/29/2016::`.:= ;