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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> �',DE State of Oregon Department of Environmental Quality <br /> Onsite Program <br /> y - 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.gov/dea/Resident al/Pages!Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(ScRers): SHETLER,JESSE I&SHETLER,KRISTIE K Telephone: <br /> Site Address:4726 Briar Knob Lp City: Scotts Mills Zip Code:97375 <br /> County: Marion Lot Size: 36.00 Acres/Square Feet(circle units) <br /> Legal Description: 071 E01 B 00300 <br /> Age of wastewater treatment system • (years) is there a service contract for system components? na <br /> Date the septic tank was last pumped 3'29'19 (please attach receipt if available) • <br /> Number of people occupying dwelling g If unoccupied. for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? Yes <br /> The above information is true and to the best of my knowledge. <br /> (� --I - ge,/9 <br /> Date(MM/DD/YYYY) Signature of Owner.or agent if present <br /> Name of person performing evaluation(please print): Josh Hansen <br /> Certification: <br /> ❑✓ installer ❑ Professional Engineer <br /> ❑✓ Maintenance Provider ❑ Environmental Health Specialist <br /> 0 National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other: DEQ approved in writing(please describe) <br /> Certification Number: 38968, M271 <br /> Business name Oregon Sewer& Drain LLC Email josh@oregonsewer.com <br /> Business address PO Box 1282 Silverton, OR 97381 phone 503-874-9414 <br /> Date of Evaluation: 3-29-19 (MAGI/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to.perfor onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155,.-/' <br /> 3-30-19i <br /> Date(MM/DD/YYYY) Signature. .'Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />