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iiikiMARION 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. 6-55-24-0o706/—PR" T <br /> MARION <br /> COUNTY t http://www.co.marion.or.us/PW/BuildingInspection <br /> SITE ADDRESS: 1 1,13 88 �V,oS U4Ie y Pei N� <br /> s;Ive'4n <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=50r' T <br /> 3 7 11 l . . North <br /> 9 <br /> m _\S ^' i <br /> • <br /> • <br /> Q� 1O <br /> h 3.91 S <br /> __ <br /> zd 1_ <br /> 5 if <br /> r ii <br /> .\ ,6t, __G ,N <br /> xe , , <br /> 4 t <br /> o- l�S` - - _ - <br /> F - D : azi' u- <br /> Io1 <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 SO Gallons/DayI HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN • <br /> - <br /> System Design Sewage Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR • <br /> - <br /> TANK Size: ' Po total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> l-5 OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: ‘,.i6.;-le) [IX double compartment <br /> Material: (on rs4C [ ] flow-through ICI have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: ` "I� Header Pipe: i� The system was installed by: <br /> Size/Mat'I I I�l Sc-h go Size/Mat'I L/ 10. 1 I I Property Owner(permittee) • <br /> ( Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es). 4 <br /> Rock and under pipe 6 I)(Drop Iytl Concrete DEQ License Number: 3 6 )' 8 <br /> Pipe total depth )Z I I Distribution I I Plastic DEQ �S <br /> Certification Number: .S <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Li SO Trench Depth Minimum 21 Maximum3_8 <br /> Curtain Drain Depth_ Signed: 17e "�. <br /> Effluent Pump: Pump Model p "3 D . <br /> Pump cycle <br /> times in minutes: on .. 0 off 145 Gallons per Cycle Company name: 0 Js\.e/ mot L-c I i a-t 5 <br /> ATT Make and Model (please print) <br /> Attach an additional sheet f components and materials not listed above. Date: _ab-3 2 <br /> (For Marion Coun se O Iv) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the syste is: [ ppr ed I I Approved with corrections: see inspection report I I Denied <br /> Signed. Title: QLIiJSDate: <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />