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N. <br /> 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 <br /> 503-588-5147 PERMIT NO. 05-07 2i <br /> MARION <br /> COUNTY http://www.co:marion.or.us/PW/BuildingInspection SITE ADDRESS: 891'5- 19L602 ,11 //t4.— <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale:.1 T . <br /> North <br /> I I <br /> 1 ( , El 161 <br /> [ <br /> /41 <br /> islk.... <br /> i'n c,..-%: <br /> I — I <br /> I y '' * f , :I- <br /> �- i 2YI-ar, <br /> • 5c.4wa <br /> Is it ik: <br /> Sto ' <br /> —.._..0 <br /> • <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 /> Gallons/DayI HEREBY CERTIFY THAT THEON-SITE SEWAGE SYSTEM IN- ' <br /> System Design Sewage Flow STALLED AT TELE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR <br /> TANK Size: /000 total gallons single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: A���Ai i^ [] double com p <br /> Material: c O.A)C- 0€7t-. [ I flow-through [4l have tested the septic tank:and certify it to be watertight. <br /> Effluent Sewer: r Header Pipe: x� The system was installed by: <br /> y S'YO � �° <br /> Size/Mat'l Size/lulat'l � �Gt-I�t�.. C.- I I Property Owner(permittee) <br /> [)Licensed Sewage Disposal.Service <br /> DRAINFIELD rock depth(inches) : Box(es) <br /> Rock and under pipe . Co.t pcDrop oncrete DEQ'License Number: CDjZ- <br /> Pipe total depth <br /> 12' !t I Distribution ..I l Plastic ��DEQ Certification'Num <br /> Drainfield Material(Alternative or perf.pipe) 3 F P <br /> Total Drainfield Footage:n(0 Trench Depth Minimum lir MaximumitD" <br /> Curtain Drain Depth. Signed: <br /> Effluent Pump: Pump Model <br /> Pump cycle times in minutes: on, off Gallons per Cycle Company name: A Cff 7 /, 7'`/7 <br /> - tR <br /> ATT Make and Model (pleasepJrint) <br /> Attach an additional sheet for components and materials not listed above. Date: JO 2 Vint) <br /> (For Marion Count Ese.Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [1Approved [ I Approved with corrections:see inspection report I I Denied <br /> Signed; <br /> Title: SIN-S l IOR-5J4 _ Date: a/I8'12Uo3 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms1Septic\S-41 As-Bui1t20I5Version201.7.doc WHITE:Marion County;YELLOW.Owner:PINK:lnstaller <br />