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t MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGEISYSTEM RECORD <br /> 5155 Silverton Rd NE r (to be completed by system installer) <br /> SALEM OR 97305 4 3 O /� i ^G7 503-588-5147 PERMIT NO. V ' ((� <br /> MARION COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 7L/q6 60- ILA'��/t S. <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= T <br /> • North <br /> r <br /> ! 1 <br /> ilils.: 6pi (• <br /> rik p ( art <br /> r,, ,, <br /> J <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 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TAN total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> M ufa r <br /> [ I double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> M erial: [ ] flow-through I I I have tested the septic tank and certify it to be watertight. <br /> Efflu t r: H der Pipe: The system was installed by: <br /> Size/Mat'l t /Mat'I I I ProperthOwner(permittee) <br /> Jicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) �' <br /> Rock and under pipe `$.Qrop I I Concrete DEQ License Number: <br /> 3-7 <br /> Pipe total depth . I J Distribution astic / <br /> a Pl DEQ Certification Number: 3(J la q <br /> Drainfield Material(Alternative or perf.pi ) <br /> Total Drainfield Footage �ir h i •.t,jY!' imum Maximum <br /> Curtain Drain Depth 1 I // I Signe <br /> Are..o.,„<- -7°-- 1116------ <br /> Effluent Pump: Pump Model 4- <br /> �/ ! �1 <br /> Pump c e - L.g ,L ,..e„- )K , <br /> times in minutes: on off Gallons per Cycle Companyname: <br /> ATE Make and Model (( (please p int) <br /> Attach an additional sheet for components and materials not listed above. Date: b/A?"a..3 <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [Approved I I Approved with corrections: see inspection report I ]Denied <br /> Signe : 1 *Title: f H SC IOa3 fi1$- _ Date: VW S 3 <br /> MC:S-4l rev:3/03;4/12;5/14: 11 IJ G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />