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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. S��-2 3 -o6-Cil-C2-- P1\el T <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection P6e <br /> SITE ADDRESS: 2 35�7 sG� ci0'd-� ` J / <br /> (� 7 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Li�1 - G°\ <br /> Scale: 1"=rb r T <br /> North <br /> ill) ..— � 7- 11G' ' <br /> 4- - Z 13e ` �� d <br /> H ( Q dd � / <br /> 1 ii'rn <br /> lta�s <br /> � � 1, <br /> % . <br /> 6:. . .v <br /> b 4 II -', <br /> I®v. �c,�[ <br /> .f <br /> _..... <br /> `M i �.. d <br /> M <br /> .... <br /> . „ ,‘ <br /> (S" <br /> 0 clee.h <br /> ' c C,),c G; -Pc Q <br /> 5 ,-•h`4., Aot -, - <br /> (show all details and dimensions necessary to lbcate all components of tite system in i:le i'uture) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow 37-5 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I .ree total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> " dd OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: �tii T� [ j double compartment <br /> Material: taelC6ae.--- [ ] flow-through [Ai have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: `/ Header Pipe: The system was installed by: <br /> Size/Mat'I i'lgi Mre.5)(er c-* F,Dft, <br /> Size/Mat'l <br /> I /ei f iGrc— I I Property Owner(permittee) <br /> " IkLicensed Sewage Disposal Service <br /> DRAINFIELD Id rock depth(inches) Box(es) I / <br /> // 1DEQ License Number: (� <br /> Rock and under pipe p) I ]Drop I IConcrete <br /> Pipe total depth I Z I I I I Distribution I I Plastic RR DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) feeO4c, Rae <br /> Total Drainfleld Footage.57..5 Trench DepthMinimum Zt( Maximum 50 �� ��� <br /> Curtain Drain Depth_ A,//L- Signed: J� <br /> Effluent Pump: Pump Model Q la <br /> Pump cycle ( / <br /> times in minutes: on v-- off DUSe- �/ 4 Gallons per Cycle 2G6 Company name: F, l,e,( 6 C.ek0. "1)j <br /> ATT Make and Model /[/I/j (please print) <br /> Attach an additional sheet for components and materials not listed above. Date:_ 1 6 ILI /i, <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 wit or ections: see inspection report I I Denied <br /> ,` �p ,c� <br /> Signed: Title: ,W � Date: LV(Z r � <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc • WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />