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Sly <br /> Oregon Department of Environmental Quality <br /> • Previous two years of maintenance records are available Dyes ale <br /> If you answered please explain below: <br /> • Previous two years of mainfermace records are attached to this foray ❑Yes []No <br /> If you answered`No,"please explain below: <br /> • Additional Comments: <br /> S. Please attack's copy ofthe following items to this form.Contact the DEQ,or the local Health <br /> Department to locate these items. ' <br /> * The septic systemps)to this farm,if available <br /> • The as-built drawings)to this faun,if available . <br /> • The Certificate of SatisSietory'Completion to this form,if available <br /> • Additional Comments: <br /> 9. Provide a Site Plan <br /> Pieasa provide a sketch ofthe complete system system(showonl acompote that were <br /> isuated�on 8 of thisform,sfa copy ofthe ` s, "'d�ag i�not available. <br /> • Please wide a sketch afthe complete system an page 8 of thus form if the original"$s built" <br /> drauvlug is not accurate or representative ofthe resting system. <br /> • If the original"as-buardrawmmgis available for copy,and the original appears to be accurate and <br /> ropresentatiite of the existing system,write"see attached asst"on page 8 of this form, <br /> redraaingthe system is unnecessary. <br /> • Additional Comments: <br /> • <br /> 10. Di claimer: <br /> This evaluation report describes the septic system as it exists an the date of evaluation and to the <br /> extent that components and operation Ogle system ares i,sonably observable.DEQ recognizes <br /> that this evaluation report does not provide assurance or any warranty that the system will operate <br /> properly in the future. ' <br /> i 1. Zhereby certify,by my since,;that the above information AO the plot plait on the next page of <br /> this farm are accurate and true to the best of my knowledge." j- <br /> 3 Z ‘• /7 <br /> Date ,,} o do S <br /> 17i,� ii�.of%�Gt11rLpI�iY •tRt i 16.X GI <br /> Page 7 of 8 <br />