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• <br /> • <br /> ri C -EVE <br /> Existing System Evaluation Report for O t <br /> Wastewater Systems• <br /> 4 APR 11 2019 <br /> ®EQ State of Oregon Department of E vironmental Quality MARION COUNTY <br /> °d Onsite Program / <br /> ""°'°"a"�' 165 East Seventh Ave, Suite 100ciaft BUILDING INSPECTION <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 <br /> visit:http://www.oregon.gov/d eq/Residential/Pages/Septic-Smart,aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Dave Shamberger Telephone: 503-932-3241 <br /> Site Address: 1114 63rd Ave NE City: Salem Zip Code: 97317 <br /> County: Marion Lot Size: 1.28 . Acres/Square Feet(circle units) <br /> Legal Description: 072W21 DD00100 <br /> Age of wastewater treatment system (years) Is there a service contract for system components? <br /> Date the septic tank was.last.pumped (please attach receipt if available) <br /> Number of peopleoccupying 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 agentif present <br /> Name of person performing evaluation(please print): Richard Westerlund.--NAWT I24931TC <br /> Certification: <br /> O Installer ❑ Professional Engineer <br /> ❑ Maintenance Provider ❑ Environmental Health Specialist <br /> E. National Association of Wastewater Technicians 0 Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 33013 <br /> Business name Ace Septic and Excavating Email office@ace-septic.com <br /> • <br /> Business address PO Box 9177, Brooks, OR 97305 . Phone 503-393-1033 <br /> Date of Evaluation: 83/z5 ZC3\ (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' 0-071-015 <br /> r1/A.1 . �. �, ��.:�e'arr '4" 4rOilit <br /> Date(MM/DD/YYYY) ign' re of Qualified Septic System Evaluator <br /> Page.1 of 8 Updated 12/29/2016 <br /> i' <br /> 1 <br />