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MARION,COUNTY BUILDING INSPECTION <br /> �': 555 COURT ST NE/PO BOS 14500 <br /> • SALEM OR 97309-5036 -. <br /> ;P-ar 6n`� INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> bPYI (to be completed by system installer) <br /> �� , ;"� <br /> SITE ADDRESS:�/3��5(� /MAY °� �' � PERMIT NO.��'".��'� •�' G" "� . <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: - 00 2 3 3 2-" 7/ZA� <br /> Scale: 1"=/00 ' io'—I qo .� x `fl.�'"North <br /> y . <br /> to'r , ,e 0 0 0 c,_-_ , .C) 0 <br /> z d ,_,......._, ,„p____ t-,?.,, i...,_, <br /> ... <br /> k-�r—x ,Y x X A' . -4,' <br /> . t' . <br /> /081 <br /> ;! <br /> LYE t,/G4-._ <br /> . S 47'\ <br /> f <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 /> System Design Sewage Flow: '$? Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCO <br /> 5J© R- <br /> Septic Tank:Size: /. Ccat/ Mel C.C4-4 vifg:m�cA/ a DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OHE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size: Mat'l Mfg: M I have tested the septic tank and certify it to be watertight. <br /> aEffluent Sewer:Size: Mat'l:OPVF0-LW The system was installed by: - <br /> Property Owner(permitee) <br /> Box(es): I 1 Distribution; I 1 Drop / I 1 Concrete;XPlastic ill Licensed Sewage Disposal Service <br /> Drainfield Pipe:Size:// ;Material:Header i/ 11 '/,Perf:-- - DEQ License Number: /7O0 & <br /> Total Drainfield Footage:WO ;Rock Depth:Total: ;Under Pipe: <br /> r/ Signed: \ `� <br /> Alternative Drainfieid Materials: / Df�Gv <br /> p�,s <br /> Trench Depth:Minimum:��f i";Maximum:7V :Curtain Drain Depth: Company namei0/k/ //'W.- r d i�'�r l',, •• <br /> (please print) <br /> Effluent Pump:Pump Model: ;Static_Head in System Ft. �' r� <br /> Date: , -,�/ <br /> Pump Cycle Time: ;Gallons per Cycle: ' <br /> Attach an additional sheet for components and materials not listed above. <br /> (For Marion County Use Only) - - <br /> The above septic system has been inspected by Marion County.The information has been determined to be accurate and the system is: <br /> Approved <br /> [ I Approved with corrections:see inspection report <br /> [ 1 Denied - dd ` _rr // / <br /> Signed Title: ClT Iln It S l� Date: �( ` (l Z� <br /> MC: S-41 k <br /> d WHITE:Marion County; YELLOW:Owner;PINK Installer <br /> rev: 8/00,6/01;3/03 <br />