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• <br /> 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 /> ix Septic Tank ❑ Cesspool <br /> 0 Dosing TankDisposal Trenches/Leach Lines <br /> O Multi-compartment Tank L Capping Fill <br /> ❑ Seepage Bed ❑ Sand Filter <br /> O 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 /> • PermitNumber(s) 03 6 55 3 pecovt-gt,,IJ c? ity <br /> • Year original septic system installed: (YYYY) ❑No record of installation date <br /> • Dates of subsequent repairs or alterations: 6o3 _(YYYY) <br /> • All plumbing fixtures are connected to the septic system ( Yes ❑No FlUnknown <br /> If you answered"No"or"unknown,"please describerbelow: 1 <br /> t') hov5z* o n 5 41-c_ i s }' t V1.or,?5d.. <br /> • Additional Comments: <br /> 2. Overall Septic System Status <br /> • Discharge of sewage to the ground surface ❑Yes No❑None observed <br /> • Discharge of sewage to surface waters :Nes ( No ['None observed <br /> • Sewage backup into plumbing fixtures ❑Yes xiNo ❑Unknown <br /> • Additional Comments: <br /> 3. Septic tank <br /> In order to fullydescribe the condition of the tank,'the septic tank mayneed to be pumped.Please <br /> p p P <br /> indicate below if the septic system tank was pumped during the course ofthis evaluation. <br /> • Septic tank was pumped during the course of this evaluation Yes ❑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 />