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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 p 1 pp <br /> MARION 503-588-5147 PERMIT NO. 5-5�P—Z3- (DOC�7i71 — r (l(IlT <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: cJ9G—C Deg) LiYI -miller OR <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: I <br /> Scale: 1"= bQ/ i T <br /> North <br /> \2° H ' <br /> ` dot 4 . <br /> t <br /> �-[ Id qt7 2G� <br /> 9.' lit <br /> ':u ... 1Ot <br /> t -l'°' do, 1 IL vt, <br /> , 'y16t <br /> t <br /> • <br /> NhO all details and dim,nsions necessary to locate all components of the system in the future) <br /> SYSTEM MATE•IALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow qso Gallons/Day <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1 oQ total gallons VI,single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES • <br /> Manufacturer: �„/.�, [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: (oftter.-- ... [ ] flow-through ILI have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer Header Pipe: The system was installed by: <br /> Size/Mat'l 1:�" S034 Size/Mat'l y�� <br /> 3U31 I I Property Owner(permittee) <br /> [I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es)Rock and under pipe Drop Concrete DEQ License Number: S 1Op <br /> Pipe total depth I I Distribution I I Plastic DEQ 9 3S <br /> //jj Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) 6 2— P'u 1../ <br /> Total Drainfield Footage l eUTrench Depth Minimum pi Maximum 1 G <br /> Curtain Drain Depth Signed:_ ..•ee, 1 eI ( <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ Kettle 1e/ • eN.I, Aris <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. Ther,information has been determined to be accurate <br /> and the system is: Approved I ]Approved with corrections: see inspection report ` I I Denied <br /> Signed: Title: Al(fl //W2i /-3 r ��( i�3 • <br /> Date: • <br /> MC:S-41 rev:3/03;4/12;5/14: 11/17 G:1 Forms\Septic 1S-4I As- ui1t2015 Version2017.doc WHITE:Marion County;YELLOW:Owner;PINK:Installer <br />