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r <br /> ' 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 503-588-5147 PERMIT NO. 2 3-Oo' 2 (pi <br /> MARION <br /> COUNTY htt ://www.co.marion.or.us/PW/Buildin Ins ection t , T kV <br /> p g p SITE ADDRESS: �CO� �S ��'Gt,gG(/'G� (� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: JJ <br /> Scale: 1"= ' T <br /> North <br /> k Z. <br /> i — a <br /> ^� a _ — C <br /> �:, 0 <br /> `I - ` <br /> • r ' <br /> ry ^ 1t Ct.,' <br /> Coal <br /> �ni� v2 <br /> s)?die. Q Ao ,t16 .�c <br /> to —r- L <br /> \ 8 . <br /> p - 0- 3z — <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 30 0 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK S'rie. /6O6, total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ManufactGrer: �f <br /> double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: ( O yLC -� [ ] flow-through RI I have tested the septic tank and certify it to be watertight. <br /> Effluent Server: . / Header Pipe: ,f- The system was installed by: <br /> Size/M AI 1 1/h/ tgize/Mat'l ®/9 puc I I Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe cv I I Drop I I Concrete DEQ License Number: 3Cf Lt 7G/ <br /> • <br /> Pipe total depth a Z I I Distribution I I Plastic <br /> DEQ Certification Number: : Z 7 3'C <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage t 5 D Trench Depth Minimum ig MaximumZ`/ <br /> Curtain Drain Depth Signed: 0/-------X" <br /> Effluent Pump: Pump PA" 30 . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ lie tt/i.2e_ 6,Assr/1cd'r' z <br /> • <br /> ATT Make and Model I (please print) <br /> Attach an additional sheet for components and materials not listed above. Date:_g/�i/z[f��s <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The in ormation has been determined to be accurate <br /> and the system is: [)4,Approved Ap oved with corrections: see inspection report [ I Denied <br /> I <br /> Signed: 1' 'tie:_�I QN Date: f <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\ ptic\S-41 As- mIt2015Version2017.doc WHITE:Marion County; YEL OW: caner;PINK:Installer <br />