8580807 - Laserfiche WebLink

Home Browse Search

• oregon Department of Environmental Quality * Previous two years of maintenance records are available Yes . I No YPV:anwerec110,"please explain below:- * Previous two years of maintenance records are attached to this form Yes No If you answered"No,"pleaseexplain below: * Additional Comments: 8., Please attach a copy of the:following items.totliis:form. Contact the DEO,-orthe local„Health Department to locatetheSeltemS. • TheSeptiC,sYStertf permit(s)to thiS'fbrm;if available * The as-builtclrawing(s)to this form,jt available ;* The Certificate of Satisfactory Completion to thS-forret„.if available * Additional Comments: 9. Provide a Plot Plan * Please provide-a sketch of the complete system(show onlysystem components that were evaluated) on Page 8 Ofthis form,if a cbpyof the original"as-built"Ormlykrig-ls nOt'aVailable. Please provide a sketch of thptorpplete. ystern on page 8 of this form if the original 'as built' drawing is not accurate Orrep.resentative of the existing.sySteni.. *, If The original"as-built"drawing is available for copy,-and the original-appears-to-be accurate,and representative of the existing'systern,write"see attached asbuilt"On-page Ktif this form, redrawing the systehris unnecessary. *- Additional Comments:- 10. Disclaimer: This evaluation tePort dekribe&theseptiesyStein as it exiStS.ori the date of evaluatioriand ththe extent that components and operation of the system• •are reasonablY:ObServable: DEQ recognizes thatthis.evaluation report does not provide assurance or any warranty that the system will operate properly:in the future. 11. :I hereby certify,bymy„signature,that the above information and the plot plan on the next page of this form are accurate and true to the best of-my•knowledge. 5/18/2018 SETH ANDERSON Date Signature of Qualified Septic System Evaluator Page 7 of 8 •