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[IditUEIMED <br /> MAR 2 9 20196'0 <br /> MARION COUNTY <br /> • BUILDING INSPECTION <br /> Existing System Evaluation Report for Onsite I1- 2 -732 <br /> Wastewater Systems <br /> State of Oregon Department of Environmental Quality <br /> Satz of Oregon <br /> Department of Onsite Program <br /> Envfmnmentai 165 East Seventh Ave, Suite 100 <br /> Quality <br /> Eugene, OR 97401 <br /> Please answer the following questions completely. Do not leave any blank responses. Write unknown if <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please <br /> visit:http://www.oreg on.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): / Telephone: <br /> j <br /> Site Address: 2 q(25 t o/e r i C C-t City: A Gl rO( Zip Code: q 70&.Z <br /> County: Mar i L9/ Lot Size: 2000 v Acres/ quare F (circle units) <br /> Legal Description: <br /> Age of wastewater treatment system (years) Is there a service contract for system components? <br /> Date the septic tank was last pumped (please attach receipt if available) <br /> Number of people occupying dwelling If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? <br /> The above information is true and to the best of my knowledge. <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): SSS R;s e i ay <br /> 0 Ce ification: / <br /> Installer [j Professional Engineer <br /> El Maintenance Provider • ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: ,3 6 32,3 <br /> Business name A G4 /) (3 rpt;n Email <br /> Business address . /.O I O:.511 r rir [.- & f S S4/e/1 AR Phone Ls3.3) _3767,732 <br /> Date of Evaluation: S- 2 7-0 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-07 55. <br /> ? 7_7 - Iq <br /> Date(MM/DD/YYYY) Signature of Qua'feed Septic System Ev. •.tor <br /> Page 1 of 8 Ipdated 12/29/2016 <br />