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/� MARION COUNTY BUILDING INSPECTION ' INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> r 5155 Silverton Rd NE (to be completed by system installer) <br /> -'-''',—-g SALEM OR 97305 - <br /> "'--R 503-588-5147 - PERMIT NO. 55S-2.6- D O O Z.3Z <br /> MAR <br /> ION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection I. <br /> Ala SITE ADDRESS: i 5 D N / <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 1 -t v i 1./ V 0 5 7 <br /> Scale: 1"= /D' T <br /> �� • <br /> North <br /> t <br /> / OP (AC <br /> r <br /> 4\ Q, `\t \Cif <br /> , ,`gip\. , ..•,h x <br /> _ .,, - <br /> r <br /> \ .\ \^ V d <br /> -max vi. <br /> C- <br /> Pq <br /> scf <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 /> System Design Sewage Flow DO Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> ` STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: ' M.0 0 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> '.". double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: 1AJiI lt!fE C1V�Si"�7E <br /> Material: 1 <br /> nO-VIa1 E �— [ ] flow-through X] I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: r/ Header Pipe: The system was installed by: <br /> Size/Mat'l fl /� i4p Size/Mat'I 2�� sal Lip <br /> Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) Milittr ���� <br /> Rock and under pipe �j/I I I Drop I I Concrete DEQ License Number: <br /> Pipe t� <br /> total depth �Z. I I Distribution I I Plastic DEQ Certification Number: .I, 4a <br /> Drainfield Material(Alternative or pelf.pipe) I qK <br /> Total Drainfield Footage gpa ' Trench}} Depth Minimum is Maximum2't <br /> Curtain Drain Depth_ 4✓W ��Signed: <br /> ! <br /> Effluent Pump: Pump Model i/M' 3 , <br /> Pump cycle p <br /> times in minutes: on off - Gallons per Cycle Company name:_ Vb.(4144 5 4l/m i it- <br /> ATT Make and Model NIItir V((please print) <br /> Attach an additional sheet for components and materials not listed above. Date: U '2-9-2023 <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: [Ac1 Approved [ ] Approved with corrections: <br /> see inspectioncr report [ ]Denied <br /> Signed: '\ Title:/1� 1 �J Date: o <br /> MC:S-41 v:3/0�14;11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County;YELLOW-Owner;PINK:Installer <br />