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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. e 00(6)SsI <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 10 ,�� gJ)L11 Rod (�W <br /> t ?jai I <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Galan <br /> 1 <br /> Scale: 1"_D" T <br /> p North <br /> 0 0 / <br /> (,.. <br /> "'S ie. A <br /> - : <br /> 9 <br /> C <br /> Qa. <br /> . 7 / <br /> L <br /> I <br /> i <br /> (show all details and dimensions necessary to locatral 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: total gallons [ ] 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 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'I Size/Mat'l I I Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: 3.6.38 14e, <br /> • Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: PT j 73 <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum <br /> Curtain Drain Depth Signed:_ y'/it/1 f9 �`� <br /> Effluent Pump: Pump Model .. ! / <br /> c <br /> Pump me �-' �/Y ___ <br /> times in minutes: on - off Gallons per Cycle Companyname: .� <br /> ATT Make and Model please print) <br /> Attach an additional sheet for components and materials not listed above. Date: .erg—/f 215 <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: (Approved I 1 Approved wit co r ctions: see inspection report 1 I Denied <br /> Signed�S"\ Title: �jfi� 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:Oivner;PINK:Installer <br />