Laserfiche WebLink
AW„, MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> -"----7- 5155 Silverton Rd NE (to be completed by system installer) <br /> ------%7A------,--*;--- SALEM OR 97305* �j' <br /> 503-588-5147 PERMIT NO. 6`7 7-; 1^ co 3z, <br /> MARION <br /> COUNTY <br /> ` http://www.co.marion.orms/PW/BuildingInspection SITE ADDRESS: 3`t0� �l/ <br /> 7 � ccE CxL(-e!' <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ ' T <br /> North <br /> \.\ <br /> cs.27v27,, <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 /> Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> e [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through [ I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'1 Size/Mat'l K, Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth (>41 Distribution 1((Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum ��7 <br /> Curtain Drain Depth o(7k; Signed3.�,--. <br /> Effluent Pump: Pump o el� / J . <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: S- .. 1 a- 2- l <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: [ ]Approved [ ] Approved with corrections: see inspection report [ ]Denied <br /> Signed: Title: Date: <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />