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iiibiMARION COUNTY BUILDING INSPECTIONSALEM INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> 503E 88-OR 97305 PERMIT NO. �5S Z/- 00 ` %g -m _01 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection ) 'RZ S (} 11� 'RV <br /> �\ <br /> SITE ADDRESS: ' <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: (ytA <br /> Scale: 1"= T <br /> North <br /> APPROVED AM�='BULUI c,.?( <br /> DRA <br /> WING N G <br />, 0,./re <br /> a � <br /> ,-.13\ <br /> 1 <br /> 1a is. , <br /> Q> <br /> . 0 <br /> ,_ I <br /> V\dir .44N 840N <br /> ,kx Are- <br /> , 0 p� <br /> S�-e R Homt3" $ <br /> O <br /> t <br /> -r `� D tl <br /> t <br /> 3 'S t <br /> I <br /> I <br /> 1 14oY t ' rc.g.._ Rio <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: /©O' total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: rt.74.c S <br /> [ double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: 4,m n el ire.,.l-z [ ] flow-through l ] I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: y <br /> Header Pipe: The system was installed by: <br /> Size/Mat'I I Size/Mat'l I I Property Owner(permittee) <br /> icensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: 3 3/^ / . <br /> C0[ 3 <br /> Pipe total depth I I Distribution I I Plastic ,. mac( <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 t� <br /> times in minutes: on off Gallons per Cycle Company name: /el. 4�. S��� 1 .� <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: ��/t7 2 j22_ <br /> For Marion Count Use Onl The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system,is: Approved I I Approved with c ections: see inspection report [ I Denied <br /> Signed: e1I — vi Date: J 1 I /2-2- <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20l5Version20l7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />