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AN,... MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> "" 5155 Silverton Rd NE (to be completed by system installer) <br /> —` SALEM OR 97305r ---6C)4( <br /> /� <br /> 503-588-5147 PERMIT NO. Y — .)1 l 2-7] <br /> MARION G�_ A <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 22-91 C7 5 So. Lir? !" g- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: ID fen-- <br /> - <br /> Scale: 1"_ ' T <br /> North <br /> 4/Cf-(/ a IrL-e,O,Q__ <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 compartmentOF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through 1 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 I ]P operty Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) 3 )•31 <br /> Rock and under pipe I ]Drop I I Concrete DEQ License Number: /J <br /> Pipe total depth I ]Distribution I I Plastic 2� <br /> DEQ Certification Number: / <br /> Drainfield Material(Altemative or pert.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum_ • <br /> Curtain Drain Depth_ Signed:. '- . - <br /> 1 Effluent Pump: Pump Model . ...- <br /> Pump <br /> Pump cycle •! �j`n t <br /> times innminutes: on off Gallons per Cycle Companyname: 4' <br /> ATT Make and Model /n (please prim) <br /> Attach an additional sheet for components and materials not listed above. Date: 6- 1.2-1 <br /> (For Marion County a Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: A 1 i r 1 ye I [ ]Approved with corrections: <br /> �see <br /> /inspection report [ ]Denied <br /> Signed: f / Title: `est ' IA.Jt �� I Date: 6) 2./ <br /> MC:S-41 -v:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YEL W:Own r;PINK:Installer <br />