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dmMARION COUNTY BUILDING INSPECTIONSA INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> 503-588-5147E EM OR 97305 PERMIT NO. 2 3 00 S q 3 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: eSq l I F-^ Ir1 AD Et) h�S C�. S <br /> c <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Jc\�'C2iIne-v O' 1 --y <br /> Scale: 1"_ T <br /> North <br /> If <br /> , \ .s... _ <br /> •. V <br /> . (.0 <br /> Vr,AP <br /> 1.\-)U(' <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 ay STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: teal n [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through [ I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'l Size/Mat'l [ I Property Owner(permittee) <br /> Xlicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) ? ( <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: l <br /> Pipe total depth I I Distribution I I Plastic T 3COt-\DEQ Certification Number: ` <br /> Drainfield Material(Alternative or pert.pipe) <br /> Total Drainfield Footage Trgactf-D/pt inirlpum M ' um_ _ <br /> Curtain Drain Depth \// Signed: V L! '% . <br /> Effluent Pump: Pump el \ BPump e times inn mminutes: onGallons per Cycle Company name: r � l <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: <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: [ I Approved I I Approved with corrections: see inspection report '::[ I Denied <br /> Signed: �� itle: Tom1— 0Jj 1 "1 e - ,--- . Date: O lZ Ai I <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-BuiIt2015Version2017.doc WHITE:Marion County; YELLOW:Oivner;PINK:Installer <br />