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7 ' <br /> 7. de <br /> err' ll2 <br /> c5 <br /> ,Existing System EvaluationRe ort for ®nsit ��� <br /> :; Wastewater Systems 1'R .19 <br /> .. ei) <br /> �i 2018 <br /> DEQ:' State of Oregon Department of Environmental Quality �Ul®/�nl Col" d ,,;o, Onsite Program Q I/vs� �l <br /> E-.0^,.... 165 East Seventh Ave, Suite 100 DC7-• <br /> Eugene, OR 97401 N <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 /> htto://www.oregon.gov/deg/Residential/Pages/Septic-Smart.asnx. <br /> Septic System Owner-Provided Information: <br /> CsAP ROTH FARO i I IC 70`6 A RITH,V.ATT HF,W n F ROT H.I!.IFF.3(O. <br /> Property Qwner(s)(Scllers); Telephone: <br /> Site Address:4914 Shannon Rd NE City: Silverton Zip Code:97381 <br /> County: Marion Lot Size: 93.46 Acres/Syuare Feet(circle units) • <br /> ACRES 93.46, 19-20: DEFERRED ADDITIONAL TAX LIABILITY SB125.18$48.43 <br /> Legal Description: <br /> • Age of wastewater treatment system 34 (years) Is there a service contract for system components? no <br /> Date the.septic tank was last pumped 3'27'19 (please attach receipt if available). <br /> Number of people occupying dwelling 3 I f 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 or my knowledge. <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 /> 0 Maintenance Provider 0 Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians 0 Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) _ T <br /> Certification Number: 38968 , M271 <br /> Business name Oregon Sewer& Drain LLC Email josh@oregonsewer.com __ <br /> • <br /> Business address PO Box 1282 Silverton, OR 97381 Phone 503-874-9414 <br /> Date of Evaluation: 3-27-19 (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 340-1171-0155: <br /> 4-3-19 // <br /> Date(IVIM/DD/YYYY) Signal're of•ualilicd Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />