Laserfiche WebLink
Oregon Department of.Environmental Qualify <br /> 1. General System Thfo ation <br /> The'Existog System Evaluation Report form contains 7 pages.Some of the questions on this <br /> form may not pertain to the system being inspected,as there axe many system designs.If you(the <br /> septic systeau inspector)are unable to answerany of the questions on this form please indicate,in <br /> writing,why this information was not available at the time the inspection was completed. <br /> ® The ,s existing septic system consists of(check all that apply): <br /> • ►-1` Septic Tank 0 Cesspool <br /> Disposal Trenches/Leach Lines 0 Capping Fill <br /> ® Seepage Bed 0 Sand Filter <br /> Other(please describe) <br /> Note:If the system is a seepage bed or cesspool contact your local County or DEQ office for further <br /> guidance. <br /> © There is a permitforthe septic system [2lYes CJNo <br /> • Permit Number / /Oiti2. <br /> .. a Date septic system installed: — 'YYYY) ®No record of installation date <br /> -, All plumbing fixtures are connected to the septic system R7Yes ONo <br /> If you answered"No,"please describe below: <br /> O Additional Comments: <br /> 2. Overall Septic System Status <br /> 8 Discharge of sewage to the ground surface ©Yes ,P4No <br /> • Discharge of sewage to surface waters DYes y' No <br /> a Sewage backup into plumbing fixtures DYes No <br /> a Additional Comments: <br /> Site Address: <br /> •i <br /> • • Page <br />