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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> -- • 503-588-5147 PERMIT NO. 6 2- 1— (3 G o2 to <br /> MARION r <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection SITE ADDRESS: Il 0 C..'cvt II Y4,I " <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 6A1GS_I. Of& q-7 3 LL(p <br /> ( Scale:1"_ ,19,s ' 111 6,4,..,t Aye. <br /> North <br /> w <br /> .... <br /> 1 <br /> -L- fes) ',eve. <br /> 4 AL= 321 ,¢.rlex r,,,,k � ) <br /> ad.. 4.-16. ' -7'0 0 - <br /> L-- htw F-1,14.1 <br /> 13 <br /> -pit4 <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 /> y <br /> `3i'- Gallons/Da 'T4cY►k C3'4t -- 1 CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> ED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: ii 14 single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> L 1 total gallons OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer, t [ ] double compartment Material: t�vl e!✓��L [] flow-through [}01 1 have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer ,! Header Pipe: t, <br /> The system was installed by: <br /> Size/Mat'l -[ Par_ Size/Mat'l L1/ (?(JC_ [ I Property Owner(permittee) <br /> Vc)Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe )& 7 J J Drop [Jd,Concrete DEQ License Number: <br /> Pipe total depth [Distribution [ J Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) FK. <br /> Total Drainfield Footage E r 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:- 63tee0vZ Cyt,,Grt:e f-ave_./. L.L <br /> ATT Make and Model c-, (please print) <br /> • Attach an additional sheet for components and materials not listed above. Date: -( ^2_I <br /> (For anion CountyUse Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> I and the`system is: f�(,l Approved I I Approved with corrections:see inspection report I J Denied <br /> �V�S' 'S�-LM,t�d�ul' `Grt3d' Date 5 <br /> Si ed: Title: r <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:1Forms\Septic\S-41 As Built2015Version20l7.doc WHITE:Marion County;YELLOW::Owner,-PINK:Installer <br />