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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 the system being evaluated,as there are many system 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 /> M.- Septic Tank q Cesspool <br /> Dosing Tank ® Disposal Trenches/Leach Lines <br /> ❑ Multi-compartment Tank ❑ Capping Fill <br /> ❑ Seepage Bed ❑ Sand Filter <br /> ❑ Other <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 ' Yes ['No ❑Unknown <br /> • Permit Number(s) '146 - ,(e,a. <br /> • Year original septic system installed: 1,41 1` (YYYY) ❑No record of installation date <br /> • Dates of subsequent repairs or alterations: tirq,b0101.1.;-.(YYYY) <br /> • All plumbing fixtures are connected to the septic system 1Yes ❑No (Unknown <br /> If you answered"No"or"unknown,"please describe below: <br /> � 1 I <br /> At.50 CC,mer ip S L/.G` WI ( aireice,-.4600)sok <br /> • Additional Comments: <br /> 2. Overall Septic System Status <br /> • Discharge of sewage to the ground surface ❑Yes ❑Nolone observed <br /> • Discharge of sewage to surface waters [1]Yes ❑No s None observed <br /> • Sewage backup into plumbing fixtures ❑Yes RNo ❑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 <br /> indicate 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 gYes ❑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 />