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a -r <br /> INDIVIDUAL ON—SITE SEWAGE SYSTEM RECORD <br /> J (to 1be completed by system installer) q <br /> SITE ADDRESS: 4 2. g S/i4 Lo F1.o�, ;;��P�EERRM-SIT NO. /v y <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: r7117 (U <br /> e p( s rl ,'..'ww10440941 ` T <br /> scale: 1 = tl D �� North <br /> NB' RI/ <br /> m- <br /> 54Au Gt <br /> I <br /> w gre <br /> -11\71. 4.t..0 , N <br /> nkA <br /> . , <br /> 01 <br /> e�o, <br /> 70 ' <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 /> Septic Tanks Size: /DO0 Mat'1: �QJIl�6 Mfg: .c I,.i FI . I HERESY CERTIFY THAT THE ON-SITE SEWAGE <br /> SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br /> STRUei IN ACCORDANCE WITH THE REQUIREMENTS OF <br /> CON- <br /> Dosing Sacks Size: Mat'l: '�- Mfg: $ THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br /> 11 ♦ QUALITY COMMISSION. <br /> Effluent Sewers Size: y Nat'l: i .Vf+ 04 I have tested the septic tank and certify <br /> it to be watertight. <br /> Eos(..): I ] Distribution; DC. Drop / b4 Concrete; I ] Plastic <br /> zIvF.I th4(•N /�If ,� The system wan installed by: /J <br /> • Drainfi.ld Pipes Size: ; Material: Header: h/ Perf: ( ] Property Owner (permitee) ^ ��1/ <br /> �4 ysD 04 Licensed Sewage Disposal Service �J( d <br /> Total Drainii.ld Foo .s Rock Depths Total: 1,0^ 1 Under pipe: '0' <br /> ifii) <br /> Trench Depths Minimum:Wy i( ; Maximum: 2 b" ; Curtain Drain Depth: Mk Signed: ems <br /> Effluent Pumps Pump Model: tr.— ; Static Head in System: e— ft. Company name: R e 4i►4L cy C ' <br /> (please print) <br /> Pump Cycle Time: 19." ; Gallons per Cycle: •#2/— _ I <br /> Attach an additional sheet for components and materials not listed above. Date: TW J L / Q.0 <br /> (for Marion County use only) <br /> The above septic system has been inspected by Marion County. The information has been determined <br /> to be accurate and the system is: <br /> [ ] Approved <br /> Approve with corr ctions: see inspection report F <br /> ] Deni <br /> Signed Title. [ Date: <br /> as-built.frm 4/95 WHITE:Marion County; YELLOW:Owner; INK:Installer <br /> MC-15-S41 <br />