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...7..si[ GLOM[ <br /> 2 9 <br /> 2019 C C <br /> MARIMARON COUNTY'0 <br /> ti:: Existing System Evaluation Report for Onsite /c, -0(,- .2..3-27 <br /> _a= Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> State°f l+ Onsite Program .. <br /> E" "ta'Quality 165 East Seventh Ave,Suite 100 --- <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 visit <br /> http://www.oregon.qovideq/Residential/Paqes/Septic-Smataspx. <br /> ,. Septic System Owner-Provided Inffor,mationn:_ LL <br /> Property Owner(s)(Sellers): ( t4 64si v a c( Telephone:563-1 7 ---21_)79 <br /> Site Address:?i fpcraped a Ci' ,t(i City: /1 Avon-, Zip Code:'MO <br /> County: M.46.1/1,Om Lot Size:2l.0 006 /7. Acres/Square Feet(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 3/// 6, (please attach receipt if available) <br /> Number of people occupying dwelling ///7 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. , ff �� G <br /> I <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Eric Zade <br /> Certification: <br /> ❑✓ Installer 0 Professional Engineer <br /> ❑ Maintenance Provider ❑ Environmental Health Specialist <br /> O National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 1-2290 <br /> Business name Carl's Septic LLC Email eric.carlsseptic@gmail.com <br /> Business address 810 Mule Deer St. NW Phone503-910-6329 <br /> Date of Evaluation: `� 17 <br /> fl (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 sta e of Oregon pursuant to OAR 340-071-0155. <br /> 4 I Li /1 . <br /> - - Date I II.1 Signature of Quah Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br /> i_. <br /> x -_tet <br />