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dimMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. c. 5_ 23—oo5oc2 _P Riliir_pi <br /> MARION <br /> COUNTY htt //www.co.marion.or.us/PW/Buildin Ins ection 8 .Su iETi^sr e O7� <br /> p' g p SITE ADDRESS: 6g7 � <br /> 9 3l 7 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: _ <br /> Scale: 1"= Na '#! I T <br /> ��,,'A Q,it vdv J,, North <br /> `V U`r — '. N,t <br /> C lir <br /> Lc. _ B-C — 2 l <br /> LS. moo` -44 r �_D _ 77� APPROVED AS-BUILT <br /> L -. az GIs, a-v - GN DRAWING <br /> L3 a;,;---- t.g5, yl .$-E — 77/ <br /> [� . rs.53 <br /> I C-P _�yt <br /> F 'LI 7j . - iif 1‘ I <br /> 58'". - /7 <br /> . mil <br /> a rD l 0 <br /> . I ° 62 <br /> p A 1 <br /> I o° o <br /> o <br /> I � l6ft J HpUS' <br /> s.--- <br /> (show all details and dimensio s necessary to locate all components of tfte sy-tem its 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 �a5 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1000 total gallons ksingle compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: UN KAb•-�iN /}I-QF/��/N� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: CatVC ./ - [ ] flow-through I I I have tested the septic tank and certify it to be waterti ht. <br /> —£ 55)&& fb <br /> Effluent Sewer: Header Pipe: <br /> The system was installed by: 1y01-10 �e,1,fl a t."-Ar <br /> Size/Mat'I Size/Mat'l p ii`t— SP,c4.! IA Property Owner(permittee) <br /> 1 1 Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe [prop I I Concrete DEQ License Number: NA <br /> Pipe total depth i I I Distribution I I Plastic NA- <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe)A-LT-, E - FLDM%) <br /> J ' - <br /> Curtain <br /> Total Drainfield Footage 3S(2 Trench Depth MinimumaZq Maximum 2g Drain Depth Signed:_ ---ydi <br /> Effluent Pump: Pump Model Nth . <br /> Pump cycle H O a wtO p <br /> times in minutes: on off Gallons per Cycle Company name: L ., <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: '/4aDia.3 <br /> (For Marion Count'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: [�Q Approved l l Approved with corrections: see inspection report l l Denied <br /> Signed: Title: etE l ( 2' Date: epo(z3 <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:Owner;PINK.:Installer <br />