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MARION COUNTY BUILDING,INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> r--�•-. ' 5155 Silverton Rd NE (to by completed by system installer) <br /> • SALEM OR 97305 <br /> 503-588-5147 PERMIT NO.. <br /> ' MARION <br /> COUNTY http://www.co.marion.or.risfPW/BuildingInspection SITE ADDRESS: , 'C 4 ! 'iYv t z r,Yc.< CO�r <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: ' <br /> I Scale 1"_ ' T <br /> _ North <br /> Pipii <br /> _ _ — <br /> ta 1 <br /> lb • ► T' <br /> q ? ` 6 <br /> as I <br /> CFat'c4,4- or 1 I 1 <br /> 1 I <br /> l 1 <br /> A P` I i <br /> M <br /> It'. l 30, 0' 1 <br /> . ilo' go' < 1 I , <br /> to <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: I at C total gallons (4 single compartment -DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer Y ti' �IKt� F� <br /> 4 f'i0✓ E double compartment OFTHE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: C�+u-+ �c. <br /> [J flow-through _]�1' have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer; Reader Pipe: The system was installed br, <br /> ro'cOwner Size/Man Size/Mat'I I p � �ermittee J,P <br /> censed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es)Rock and under pipe . [ ]Drop [I Concrete DEQ License Number 3 0 C <br /> 5)-,5 <br /> Pipe total depth 1 ).Distribution 1.1 Pic- DEQ Certification Number: (11 <br /> Drainfleld Material(Alternative or perf.pipe)C 2 Ft.,..) t._J j efoso,.t to,l e2 <br /> Total.Drainfield Footage Trench Depth Minimum 1'LMaximum / Xt...-- <br /> Curtain Drain Depth . Signed: 1-:— <br /> Effluent Pimp: Pump Model J- • k 6 5 )4 e_. -srcs <br /> Pump cycle j, 4. 25fr • <br /> times in minutes: on. off Gallons per Cycle Company name +�/ �` �5. ji C <br /> (please print <br /> ATF Make and Model 0IteNtto AV 7.0O /' <br /> Attach an additional sheet for components and materials not b <br /> listed above. Date: 'T 1?✓ 2_ <br /> (For Marion CountvUse Only) The above septic system has been inspected by Marion County. The information has been determined'to be accurate <br /> and the system is;'/Appro d ]-Approved with corrections see inspection report ( ].Denied <br /> Si-Did: /YUh a Title: t;.1.1 YJ 10 J ,3! Dater I • 1�� <br /> MGc'S-41 rev:3/03;4/12`;5/14;11/17 G:LForms4Sepdc\S-4I:As-Bui1t2015Versioii2017idoc WHITE:Mar on County;YE OW.•O er,PINK-Installer <br /> r' <br />