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a , MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> —=. r SALEM OR 97305 <br /> --! 503-588-5147 PERMIT NO. J j' -- a.3 - Ccs q 64 I <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspeetion SITE ADDRESS: /-j(1g l44A✓-y— fQ <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 517tie,1,-WM I CM- 97g ! <br /> Scale: 1"_ . T <br /> �ve`�� North <br /> AC - ►o'6" 19 <br /> 11 93G - 33' 1 <br /> 1-13,H D - it ' S 4 <br /> II ist7 - 3g' 0 R , <br /> 0 <br /> VI Cpc-i $4 <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 37. Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I e.-e-AD total gallons pQ single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> 1 OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: 2(�a(hvG.. [ 1 double compartment <br /> Material: p I46 -'C [ 1 flow-through pc]I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: 1_ Header pipe: The system was installed by: <br /> Size/Mat'1 PUS Size/Mat'1 T‘ [ ]Property Owner(permittee) <br /> In Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) / <br /> Rock and under pipe / [ ]Drop I Concrete DEQ License Number: 3 <br /> Pipe total depth 1 1 Distribution 1 1 Plastic <br /> DEQ Certification Number: IZT `1 ,/ <br /> Drainfield Material(Alternative or perf.pipe) * Iei i.,k_ D!Alt/ <br /> Total Drainfield Footage — Trench Depth Minimum Maximum <br /> 1 <br /> Curtain Drain Depth Signed: <br /> Effluent Pump: Pump Model . <br /> Pump cycle times in minutes: on _ _off — Gallons per Cycle Company name:_ CV-cppvt €# t v '' Dr z iK L. <br /> ATT Make and Model — c� (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: I g-,_' 1 <br /> (For Marion Co my Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system i Approved [ ]Approved wi orrect' ns:see inspection report [ ]Denied <br /> /dam f /1 l <br /> Signed- Title: ` Date: / <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 />