Laserfiche WebLink
. <br /> • , <br /> REcENED <br /> =- Existing System Evaluation Report for Onsite <br /> JUN 012018 <br /> Wastewater SystemsiviARiON COUNTY <br /> BUILDING INSPECTION <br /> DEttState of Oregon Department of Environmental Quality <br /> D meOreGon <br /> m Onsite Program <br /> E"'"'°""' ' 165 East Seventh Ave, Suite 100 <br /> Maly <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.gov/ded/Residential/Paqes/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Telephone: <br /> Site Address: 7 7 4 5" pot)o L h L-/1) City: .6a (er) Zip Code: ?73 l 7 <br /> County: Lot Size: Acres/Square Feet(circle units) • <br /> Legal Description: <br /> Age of wastewater treatment system 3 (years) Is there a service contract for system components? ,A <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): <br /> Ceification: <br /> I1 Installer ❑ Professional Engineer <br /> ❑ 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: r) c 4 b3 z,3 <br /> Business name A\ C•4 t D /1 Q rake /1 . Email I a 4 Lf 'O")1 tag 11(tl 5 PIA., I ••G 0/1 <br /> Business address 3 b g 0 k a S h 6'1;C vitt)/ £ S4leii Phone (coo) q 32 2�© <br /> Date of Evaluation: 6- I - f / (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 340-071-0155. <br /> 6- f- is <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />