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'M ' 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. 20— Ud i) / 3 69 <br /> MARION <br /> COUNTY htip://www.co.marion.or.us/PW/Buildinglnspection 9 �6� 7 / <br /> SITE ADDRESS: �/ IL ti.47/4)---CJ �LA.-5 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=_' T <br /> North <br /> 1 <br /> Jt/ 1 <br /> 3 t <br /> Pr ./q' o0 <br /> im <br /> t <br /> /I <br /> 9 `1-� H' <br /> ti3 ' <br /> So ' <br /> so r b,�\\ <br /> I <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 /> Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: total gallons [mangle compartment DANCE.WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> 1,L}p��{�S [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: L•/-4-- [ ] flow-through /14 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: if • Header Pipe: The system was installed by: <br /> Size/Mat'1 L' L.✓-' ✓ Size/Mat'l I I Property Owner(permittee) <br /> IX Licensed Sewage Disposal Service <br /> DRAINFIELD -0 ioc'k depth(inches) Box(es) <br /> Rock and under pipe 12. [ ]Drop [ ]Concrete DEQ License Number: <br /> 37�1i <br /> Pipe 't <br /> total depth 1� Distribution i 1 Plastic <br /> DEQ Certification Number: 1 7-3.1 7 <br /> Drainfield Material(Alternative or pert.pipe) Xe, <br /> 1` it <br /> Total Drainfield Footage Trench Depth Minimum 2 ki Maximum W <br /> Curtain Drain Depth_ Signed: 6 --- ..„).----7. <br /> Effluent Pump: Pump Model I <br /> Pump cycle{^ S�ftCs <br /> times in minutes: on off Gallons per Cycle Company name:_ l l.` _ <br /> ATT Make and Model A-X �-t 15‘t a o rr • (please print) <br /> Attach an additional sheet for components and materials not listed above.'� .Q�1 .l Date: f— S ' 1 0 <br /> (For Marion County Use Only) The above septic system has been inspected arion County. The information has been determined to be accurate <br /> and the system is:,]::].Approved [ ] Approved with corrections:��j see inspection report [ ]Denied <br /> Signed: VAY) <br /> c <br /> Title: C�14—V\Y I a L�'-f-OC Ia _ 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 YELL W:Own r;PINK:Installer <br />