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' MARION°COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> dial <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> ® �j <br /> 503-588-5147 PERMIT NO. 5' S "2-3 -&25 2 ® � 1 i /" 0 T <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 75 7ei „sr i RI. gut= <br /> -r44nC— 0 e <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Sc le: 1"=70' 010 ,./, .i-IZ 4. <br /> North <br /> ' � _D 1 O1 <br /> Zr P g , c ram/, <br /> 0 <br /> .Ni la <br /> s <br /> 0 7g- <br /> a o ' <br /> to <br /> Si <br /> Iv o <br /> -25 <br /> 13' <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 /> �4�0 Gallons/DayI HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: too total gallons X single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: Not. <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: Cale C . [ ] flow-through IX 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'I I I Property Owner(permittee) <br /> f 1 Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) �,1 /.B <br /> Rock and under pipe [ I Drop ,4Concrete . DEQ License Number: �r <br /> Pipe total depth A Distribution I I Plastic 3� <br /> pp DEQ Certification Number: 8 <br /> Drainfield Material(Alternative or perf.pipe) t 4).LI <br /> Total Drainfield Footage Trench Depth Minimum Maximum <br /> Curtain Drain Depth Signed: Ck46 <br /> Effluent Pump: Pump Model . <br /> Pump cycle 6 <br /> times in minutes: on off Gallons per Cycle Company name:_ C. j c.1 `4 e.9s :4 15 <br /> ATT Make and Model please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 1 i/2.' <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: (J Approved I I Approved with co rections:/see inspection report [ I Denied / <br /> Signed: ` - Title: ' �`I J (XJ rZ'Z � Date: I/C o(2-S <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />