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Oregon Department of Environmental Quality <br /> 1. General System Information <br /> The Existing System Evaluation Report form contains 8 pages.Some of the questions on this <br /> form may not pertain to they system being evaluated,as there are many systems designs. If you(the <br /> septic system evaluator)are unable to answer any of the questions on this form please indicate,in <br /> writing,why this information was not available at the time the evaluation was completed. <br /> * The existing septic system consists of(check all that apply): <br /> x ISeptic Tank ; {Cesspool <br /> I I Dosing Tank { x Disposal Trenches/Leach Lines <br /> Multi-compartment Tank j Capping Fill <br /> 'Seepage Bed l j Sand Filter <br /> IOther(please describe) <br /> Note:Cesspools may be used only to serve existing sewage loads and if failing only be replaced with <br /> a seepage pit system on lots that are too small to accommodate a standard system or other alternative <br /> onsite system. <br /> * There is a permit for the septic system t_ Yes [ I No i x !Unknown <br /> * Permit Number(s) <br /> * Year original septic system installed: (YYYY) L x No record of installation date <br /> * Dates of subsequent repairs or alterations: (YYYY) <br /> * All plumbing fixtures are connected to the septic system ?Yes I No { x 1 Unknown <br /> If you answered "No,"or"unknown,"please describe below: <br /> NO ONE HOME TO CONFIRM FLOW <br /> * Additional Comments: <br /> 2. Overall Septic System Status <br /> * Discharge of sewage to the ground surface I i Yes I x i No ! None observed <br /> * Discharge of sewage to surface waters [ j Yes x No I i None observed <br /> * Sewage backup into plumbing fixtures r i Yes x {No 1 Unknown <br /> * Additional Comments: <br /> 3. Septic tank <br /> In order to fully describe the condition of the tank,the septic tank may need to be pumped. Please indicate <br /> below if the septic system tank was pumped during the course of this evaluation. <br /> * Septic tank was pumped during the course of this evaluation x j Yes 1--1 No <br /> * If the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. <br /> septic system owner declined to have the tank pumped etc): <br /> Page 2 of 8 <br /> L <br />