I•l·1
StaleofOregonDepartmentor
Environmental
Quality
ExistingSystem EvaluationReportforOnsiteWastewaterSystems
StateofOregonDepartmentofEnvironmentalQualityOnsite Proram
165East7 Avenue,Suite100
Eugene,Oregon97401
Pleaseanswerthefollowingquestionsascompletelyaspossible.Ifyouareunabletofilloutanypartofthisformindicateinwritingwhythesesectionswereleft blank.RefertoOAR 340-071-0155.Formoreinformation, visit
SepticSystem Owner-ProvidedInformation:
PropertyOwner(s)(Sellers):------Telephone:__SiteAddress:_City:ZipCode: ___
County:_LotSize:Acres/SquareFeet(circleunits)
LegalDescription:------
Ageofwastewatertreatmentsystem(years) Tsthereaservicecontractforsystemcomponents?__Datetheseptictankwaslastpumped (pleaseattachreceiptifavailable)
NumberofpeopleoccupyingdwellinIfunoccupied,forhowlonghasitbeenvacant? _Theaboveinformation istrue andtothebestofmyknowledge.
Date(DDIMMNYYY)SignatureofOwner
Nameofpersonperforminginspection(pleaseprint):------
Certification:
0Installer
0MaintenanceProvider
DProfessional Engineer
DEnvironmentalHealthSpecialist
0NationalAssociationofWastewaterTechnicians
DWastewaterSpecialist
DOther:DEQapprovedinwriting(pleasedescribe)___
CertificationNumber:
Businessname------Email------
Businessaddress____
Phone_
Dateofinspection:(DD/MM/YYYY)
Iherebycertify,bymysignature,thatImeetallofthequalificationsrequiredtoperformonsitewastewatersysteminspectionsinthestateofOregonpursuanttoOAR340-071-0155.
Date (DD/MM/YYYY)SignatureofQualifiedSepticSystemInspector
l. GeneralSystemInformation
TheExistingSystemEvaluationReportformcontains7pages.Someofthequestionsonthis formmaynotpertaintothesystembeinginspected,astherearemanysystem designs.Ifyou(thesepticsystem inspector)areunabletoansweranyofthe questionsonthisformplease indicate, inwriting,whythisinformationwasnotavailableatthetimetheinspectionwascompleted.
•Theexistingsepticsystemconsistsof(checkallthatapply):
Other(pleasedescribe)__
Note:Ifthesystemisaseepagebedorcesspoolcontactyourlocal CountyorDEQofficeforfurtherguidance.
•Thereisapermitforthesepticsystem DYes ONo
•Permit Number------
•Datesepticsysteminstalled:_____(YYYY)DNorecordofinstallationdate
•Allplumbingfixturesareconnectedtothesepticsystem DYes ONoTfyouanswered"No,"pleasedescribebelow:
•AdditionalComments:
2.OverallSepticSystemStatus
•Dischargeofsewagetothegroundsurface DYes DNo
•Dischargeofsewageto surfacewaters OYes DNo
•Sewage backupintoplwnbingfixtures DYes DNo
•AdditionalComments:
3.Septictank
Inordertofullydescribetheconditionof thetank,theseptictankmayneedtobepumped.Pleaseindicatebelowifthesepticsystemtankwaspumpedduringthecourseofthisinspection.
•Septictankwaspumped duringthecourseofthisinspection DYes ONo
•rftheseptictankwasNOTpumpedduringthecourseofthisinspection,pleaseexplainbelow,
e.g.septicsystemownerdeclinedtohavethetankpumpedetc:
•Theseptictankmaterialis:
0Concrete
0Steel
0Plastic
0Fiberglass
0Other(explain)__
0Unknown
•Istheseptictankaccessible? DYes ONo
•Septictankvolume(ingallons)_
•Septictankrisersareatgroundlevel DYes ONo
•Tankappearstobewatertightandingoodcondition DYes DNo
Ifyouanswered"No,"pleasedescribetheconditionoftheseptictankbelow.Forexample,evidenceofgascorrosion,cracks,leaks,etc.
•Septictanklid(s)isintact DYes ONo
•Septictankbafflesandelbowsareintact DYes ONo
•Effluentfilterispresent OYes ONo
•Effluentfilter isfreeofdebris DYes ONo
•Liquidlevelintankrelativetoinvertofoutlet DAt DAbove DBelow
•Scumlayer_(inches)Sludgelayer(inches)
•ScumandSludgelayermorethan35%ofthetotaltankvolume DYes DNo
•AdditionalComments:
4.DosingtankIPumpBasin
Dosingtanks,wherepresent,haveapumpthatsendseffluenttothesoilabsorption field(leachfield).Notallsepticsystemdesignshave adosingtank.
•Thesepticsystemhasadosingtank OYes ONo(If"No,"skiptherestofsection4)
•Dosingtankcapacity(gallons)
•Dosingtankmaterial______
•Dosingtankappearstobe watertightandingoodcondition OYes DNo
•Dosing tanklid isintact OYes ONo
•Electricalcomponentsaresealed andwatertight DYes DNo
•Pump/siphonisfunctional OYes ONo
•TypeofPump DDemanddose DTimedose
•Pumpcontrolmechanismisfunctional(floats,pressuretransducer)OYes DNo
•Thereisa highwateralarmOYes ONo
•Thehighwateralarm(audibleandvisual)isworking OYes ONo ON/A
•Typeofscreen____
•Screeniscleanandfreeofdebris DYes ONo
•Scum/sludgepresentinDosingtank DYes DNo
•Scumlayer(inches)Sludgelayer(inches)
•Additional Comments:
5.Soilabsorptionsystem
Thesoilabsorptionsystemisasetoftrenchesthatreceiveseffluentfromtheseptictankandfilterstheeffluentbeforeitentersthegroundwater.
•Thesepticsystemhas asoilabsorptionsystemOYes ONo
•Absorptiondistribution OEqual 0Serial OPressure OEqualviapressure
•Absorptionlinesconstructionmaterial:
DGravelandpipeOChamberOTileOPolystyrenefoamandpipeOOther_
•Absorptiondfatributionunit(s)(dropbox,hydrospiltter,equaldistributionbox)Olntact ODamaged ON/A
•Absorptiondistributionunit(s)arefreeofdebrisorsolids DYes ONo
•Locatealldrainlinesinsoilabsorptionsystem DYes DNoTotallengthofdrainlines(ft)
•Absorptionareaappearstobefreefromroads,vehiculartraffic,structures,livestock,deep-rootedplantsetc.
DYes DNo
Ifyouanswered"No,"pleasedescribebelow:
•Absorption areaappearsto befreefromsurfacewaterrunoffanddownspouts DYes DNo
•Evidenceofpondinginabsorptionareaor distributionunit(s) DYes DNo
•Theabsorptionreplacementareaassignedinthe"as-built"drawingappearstobeintact
DYesONo
Ifyouanswered"No,"pleaseexplainbelow:
•AdditionalComments:
6.SandFilterSystem
Therearedifferentsandfiltersystemdesigns usedinOregon.Noteverysandfiltersystemwillcontainallofthecomponentsmentionedbelow,e.g.pumps. TheownerofasandfiltersysteminstalledonorafterJanuary 2,2014mustmaintainanannualservicecontractwithacertifiedMaintenanceProvider.Maintenancerecordsshouldbeavailablefromthesystemowner,orthecontractedMaintenanceProvider.Pleaseattachcopiesoftheprevioustwoyearsofmaintenancerecordstothisinspectionform.
•ThesepticsystemhasasandfilterDYes DNo(If"No,"skiptherestofsection6)
•Typeofsandfilter
0Intermittent
0Re-circulating
0Bottomless
•Sand filtercontainerappearstobewatertightandingoodcondition DYes DNo
•Sandfilterappears tobe freefromroads,vehiculartraffic,structures,livestock,deep-rootedplantsetc.