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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 ,,pp 99� <br /> 503-588-5147 PERMIT NO. p� 3'��9� L7`I-�� � <br /> SITE ADDRESS: <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspectionq rl 19� <br /> J E l�F'f}� f>/� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> hl1-"'.--"— <br /> Scale: 1"_i T <br /> 5 E L /9 /'i e /4 D North <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 L)TO Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 15 OO total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: Idle F11=TA67-19 <br /> double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: p®LyPRopyI P/r'C [ ] flow-through [4I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: [leader Pipe: The system was installed by: <br /> Size/Mat'I 4' PVC Size/Mat'I al Met IQ Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe (p pc Drop I I Concrete DEQ License Number: <br /> Pipe total depth !a- I I Distribution I I Plastic DEQ Certification Number: <br /> Drainfield Material(Alternative or pert pipe) roaRf PIPE <br /> Total Drainfield Footage q 9O Trench Depth Minimum �4"I Maximum_2'b ` <br /> Curtain Drain Depth /I//A Signed:_ rokeoedit, <br /> Effluent Pump: Pump Model /!�/A . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: • <br /> ATT Make and Model I (please/ p�lrint) <br /> Attach an additional sheet for components and materials not listed above. Date: ` f ( ( r <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: 141 Approved I I Approved with corrections:l see inspection report I 1 Deniedyzi <br /> / y/ <br /> Signed: Title: AF L+S (Ci�Z1"' ' Date: t(( 2 ( ( -27 <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 />