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p\i%, MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> `''-- d 51, •. 'd NE (to be completed by system installer) <br /> _..;-,, a -' ALE 0'\9 '05 <br /> 503-588-5147 / PERMIT NO. S S 5 — a 3-00 G,7,3a - Q R PAN <br /> MARION <br /> COUNTY h •. "".co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: IS(o8 C C4is�1.V <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 1.1 •,,,lc, 0„,\,y <br /> Scale: 1"_ a.0' <br /> . North <br /> i C 0 4--/V ZU va,,Ac. <br /> 11,5 <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 /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow 3 7.S Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: t O 0 0 total gallons single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> y� <br /> �. ` G„��� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: Q\LL '�1:C [ ] flow-through j ] I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The s stem was installed by: <br /> Size/Mat'I "('' /-j3, Size/Mat'l ,j.i operty Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I ]Concrete DEQ License Number: A) (A <br /> Pipe total depth j,rDistribution Plastic <br /> DEQ Certification Number: .JV I A <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum F rI <br /> Curtain Drain Depth Signed:_ G�i+t tie r� C. p if e- Matrt,Sej._ <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: /J (A <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: ?/! 5 t t3 _� <br /> (For Marion CountyUse 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 [ Approved with corrections: see inspection report [ I Denied.' <br /> Signed: Title: //O L Date: �V a3JX <br /> MC:S-41 rev:3/03;4,12;5/14;11/17 G:\Forms\Se ic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW.:Owner;PINK:Installer <br />