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MARION COUNTY BUILDING INSPECTIONAm <br /> INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system Installer) <br /> SALEM OR 97305 <br /> MARION 503-588-5147 PERMIT NO. ,j c5'_7_1-per!£/.5 3 <br /> COUNTYhttp://www.co.ntarlon.opus/P W/BuildtnglnspectLolt <br /> SITE ADDRESS:3SV. S failk .57J'S'- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale:r'_ t <br /> • <br /> North I <br /> w /et✓afxra p,/, Po!)1 7eink; <br /> 14/ plq..17-(oWt J7lnbLt744e2"7 8c' <br /> • <br /> • <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATXONt <br /> System Design Sewage Flow Gallons/Day I HEREBY CERTIFYTHATTHEI ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Site: /(Da042> total gallons ;1 single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer-Ws-4/17112r7ral' []doubleemnpnrbnent OFTHE ENv1RONMEh?AL QUALITY COMMISSION. <br /> Material: Pay I)flow-through 14 I have tested the septic tank and cenify it to be watertight. <br /> Effluent Sewer. Header Pipe: The system was installed by: <br /> SlzeiMat7 Size/Mat'1�! _ I !Property Owner(permittee) <br /> kLicensed Sewage Disposal Service <br /> •DRAINFIELD rock depth(inches) Box(es) <br /> Rook and. under pipe I I Drop I 1 Conmete DEQ License Number. 3 7.2-.2 7— <br /> Pipe total depth �.J <br /> (fS Aistrlbution PI' DEQ Certification Number.. Z 7'6 <br /> Drainfield Material(Alternative orport;pipe) <br /> Total Grainfield Footage Trench Depth htinimmn Maximum,__ <br /> Curtain Dr inDepth. Signed- <br /> Effluent Pump:Pump Model,_ <br /> Pump cycle pp/� <br /> dines in minutes:an off Gallons per Cycle Company name:i4Zss„Sal Se$4 4495. L „C <br /> ATT Make and Model r (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: P 5/'P 92.( _ <br /> IPor Marlon 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: [ 1 Approved I )Approved with corrections:see inspection report [ I Denied <br /> SIgned: Title:. Date: <br /> MC:841 rev:3/03;4/12;5/14;I1/I7 G:\FonnstScprictS41 As-Buitt2015Vetsion2017,doe WHITE:Ararlon County;YELLOIPOwner,•PINKtnsratler <br />