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�w MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> •"- - 5155 Silverton Rd NE (to be completed by system installer) <br /> ~--` ':::' SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. ,SSS -iq-mitts 6-PE <br /> MARION s <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITEq 6 S i !Sealy c..r�cxLNs <br /> ADDRESS: !' <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: ✓ —_ 1e <br /> Scale: 1"_ 110t' .-. --- ''y t <br /> 3 t North <br /> ----- ----. 'L------>-------- / g ' L 7— 33 <br /> 4 -Qs res <br /> �'`�� 6G 6t, r <br /> Av <br /> OGS/ <br /> \\-\\°"\- . . ‘4-• 4 `1" .: <br /> ______—_:"_______________tysm <br /> S ,a <br /> \ - 0 <br /> t2° <br /> ----: <br /> 7----:--------- <br /> iv ,... _ , <br /> i.„, <br /> A ‘ <br /> ..._. <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 �S 0 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> ODD total gallons [a] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND\THE RULES <br /> TANK Size: <br /> 1 I I- OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: 1,,.0i i'-fe./ [ ] double compartment <br /> Material: Cart Grc [ ] flow-through ]xLI 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 LII" 30 311 Size/Mat'l II�-36j1 I ]Property Owner(permittee) <br /> kLLicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe [ADrop [Concrete DEQ License Number: 3 L I' 8 <br /> Pipe total depth I i Distribution I ]Plastic <br /> _ DEQ Certification Number: B 3 s <br /> E7--Drainfield Material(Alternative or perf pipe) Z VOL, <br /> Total Drainfield Footage Trench Depth Minimum_ Maximum <br /> Curtain Drain Depth Signed: Pa/kW <br /> Effluent Pump: Pump Model • <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: .. . <br /> (For Marion Cou v 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: 't , pproved [ ] Approved with corrections:�/� see inspection report [. I Denied <br /> Signed: Title: r4 ' 0 t/•/.SDate: '// l <br /> MC:S-41 rev:03;4/12;5/14;11/1 /: .orms eptic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW:Owner;PINK:Installer <br /> A 1dkv� 1/ v11c s <br />