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AimMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be com feted by system installer)503-588-5147 PERMIT NO. �5 0 -d,I - 00 <br /> MARION <br /> COUNTY htt '//www.co.marion.or.us/PW/Buildin Ins ection SITE ADDRESS:-30g aY-3n <br /> I <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Hil*C1-6 ) <br /> Scale: 1"= ' T <br /> North <br /> wAiii <br /> 1\)D v <br /> O �, l'ill► , , ► <br /> ; <br /> / 0 <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 Gallons/Day STALLED 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 /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through [ ] 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'I Size/Mat'l I Property Owner(permittee) <br /> [ ] 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 I I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum <br /> Curtain Drain Depth Signed: <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 co e d materials not listed above. Date: <br /> (For Marion County U •nly) `-"a above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the sys -m is:'[ I Appr aye I I I Approve• with corrections: see inspection/ ec � report 1 I Denied C� <br /> /Do <br /> Signed: 1 A A4 `A. Title:4 /J\ V" �L� 1 `� P C Dater `-' _ _ <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20l5Version2017.doc WHITE:Marion County; Y LLO :Owner;PINK:Installer <br />