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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 NO55 ) 6,02-25S. <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection �' S <br /> SITE ADDRESS:33,Z 99/YS4n a d+2 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' T <br /> North <br /> gAic/e flew <br /> Repiacej -2 51- Popp sox, <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 /> [ ] 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'l _ Size/Mat'l f I Property Owner(permittee) <br /> t4Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) �G Z <br /> Rock and under pipe Drop 4 Concrete DEQ License Number: � / Z2 / <br /> Pipe total depth I ]Distribution Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.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:H-1 ,12 Ste!`1/ie e.S LLQ <br /> ATT Make and Model // (please print) <br /> Attach an additional sheet foryet)mponents and materials not listed above. Date: - <br /> ffor Marion County'se Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the syste , • : [j,]/ pr ved [ ] Approved with corrections: see inspection report [ ]Denied <br /> Signed: � f"'�'� Title: �� ` Date: <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County;YELLOW:Cjwner;PINK:Installer <br />