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iiihiMARION 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. 2—Z O D\LZEI <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: l�� peke kir/ k- (J1- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= T <br /> North <br /> c <br /> .IAA t -3 0 <br /> Li <br /> .,� <br /> - <br /> r v ;l) <br /> -- is /° <br /> s <br /> t g <br /> �fi'-f' s � 'rt�� �� r,� <br /> - - - <br /> I <br /> e.ram('ev./ Awl-, <br /> BO. 6Li' <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 Z 25 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I OW total gallons single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> ) 1N`� } �� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: r t Ire L [ ] flow-through [L 4 have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer:„ Header Pipe: ii The system was installed by: <br /> Size/Mat'I (if (Gln Lt() Size/Mat'l LI 5[ - 40 I I Property Owner(permittee) <br /> (, 4'Eicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I([Drop I I Concrete DEQ License Number: 1 Z7$9 <br /> Pipe total depth I I Distribution N Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage��� Trench Depth Minimum Maximum <br /> ` <br /> Curtain Drain Depth Signed A <br /> Effluent Pump: Pump Model <br /> Pump cycle _ t_ C, <br /> times in minutes: on off Gallons per Cycle Company name: 1�Cl '1 1 , ]o C.C.S. ATT Make and Model (ple a print) <br /> Attach an additional sheet for components and materials not listed above. Date: (41_42_ <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [X IVi'1 Approved� 111 A• s ro•:s with corrrections:ps/ee� Utiinnsspeecctiionn report ( [ Denied <br /> Signed: <br /> � 2 - ACV i I i 614� ) J i� Date: ' <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: vner;PINK:Installer <br />