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NN, MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> '"'r`°- 5155 Silverton Rd NE (to be completed by system installer) <br /> -•4 [:. SALEM OR 97305n -� <br /> 503-588-5147 PERMIT NO. ,SSS-z� —Oe,6 7 9/1 -P -..- <br /> RII <br /> MARION <br /> COUNTY htt //www.co.marion.or.us/PW/Buildin Ins ection y ®� S'�, r ya.' <br /> P' g p SITE ADDRESS: •�Q� 1 ,� Oma, SC C <br /> ©fC <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=So ' • I 4- <br /> North <br /> a- 3 <br /> il9 - 0 ::: Syi <br /> ttt5C g - ® = /2o <br /> R.Q4.tr <br /> I1 Cir <br /> 0 <br /> s 2I ISo;' <br /> ri . . <br /> tib_. - { i <br /> d J �� I I / <br /> I1 . <br /> l izsi <br /> _____________ NCe- -- - <br /> (show all details•and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow Igo Gallons/Day <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: ] �r/o total gallons A—single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> 1 OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: t„ioa;-E.r� [ ] double compartment <br /> Material: lrfr)L r&-/G.--- [ ] flow-through IAI have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer Header Pipe: „ The system was installed by: <br /> Size/Mat'l 1,+i 3011 Size/Mat'l q Sa 1 I I J Property Owner(permittee) <br /> J/J Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe [}.Drop 1/4_Concrete DEQ License Number: 3 U 19 6 <br /> Pipe total depth IDistribution I I Plastic <br /> I DEQ Certification Number: e 3 S <br /> Drainfield Material(Alternative or pert.pipe) £7. 44101-✓ <br /> Total Drainfield Footage L-154) Trench Depth Minimum V( Maximum_30 JC✓ � ham( <br /> Curtain Drain Depth Signed:_ I <br /> Effluent Pump: Pump Model . <br /> 1 Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ gt/f <br /> �� 4,--_ <br /> 4 C ai, 1 CIS <br /> (please print) <br /> ATT Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: 6 /.?/74 <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [y4 Approved [ ] Approved with corrections: inspection report [ I Denied �,, / <br /> Signed: Title:\ Title: / ! S r ,l d ^ , Date: `� !i <br /> MC:S-4 AIIPP/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW:Owner;PINK:Installer <br />