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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.SST-73 - sin 8- P Il (7 -G I <br /> MARION <br /> COUNTY htt //www.co.marion.or.us/PW/Buildin Ins ection Imo/L/7 , .�-�-r ev <br /> p' g p SITE ADDRESS: 5 i <br /> AS-BUILT PLAN OF CONSTRUCTED SYS"'EM: 11"rere-C- OR ', <br /> Scale: 1"_`.0 ' a T <br /> North <br /> 49- �Q ' 36l a44, <br /> 1) _ Q ; 16' see <br /> 0 ® cInS 'am NeU. <br /> mg / C: ,,e.,1/ <br /> (-v. 'o 3�L1 Po A <br /> ml <br /> -R <br /> , 51 <br /> V <br /> C'et `IO tS <br /> �, 5. <br /> 4 <br /> G,- <br /> wcl[ Qcs 141‘5 <br /> Or 4,-e loty <br /> r"cKihs ,x—es $ <br /> (show all details and dimensions necessary to locate all components of the sys '-m in the uture) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow 37� Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> [)Q single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> TANK Size: iI WO total gallons <br /> Manufacturer: wA [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: Co.,rre It [ ] flow-through I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: ,i The system was installed by: <br /> �� <br /> Size/Mat'l 6l Fa tia Size/Mat'l q 1oJ4t I I Property Owner(permittee) <br /> IA Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es)Rock and under pipe I I Drop JA.Concrete DEQ License Number: 16 i q e <br /> Pipe total depth _VI Distribution I I Plastic DEQ @ 35 <br /> Certification Number: U <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum l <br /> Curtain Drain Depth Signed: �-� v4"AP/f <br /> Effluent Pump: Pump Model . <br /> Pump cycle 6? JAG( 67—i-cq. .4)i <br /> times innminutes: on off Gallons per Cycle Company name:_ 5 <br /> ATT Make and Model pp (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: fJ/l s/2.3 <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 I Approved with corrections: see inspection report I I Denied <br /> Signed Title: �� 10`�3-j Date: O (+17,3 <br /> . MC:S-41..rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20l5Version20l7.doc WHITE:Marion County; YELLOW:Oivner;PINK:Installer <br />