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iiiiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer)503-588-5147 PERMIT NO. 2 _ 00 I ot 1 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection SITE ADDRESS: ��(� MIJ C t <br /> S F--- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> .-C.\e•' v2 a1 n1 <br /> Scale: 1"= T r <br /> North <br /> I 1)1�Je.n, <br /> av 11,57p <br /> Sepi;c <br /> El loi - 1 _. Too*, <br /> I` <br /> 5' 3 <br /> Tx niL <br /> F <br /> 1 I —Th23 <br /> •1e <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 /> TANK Size: 1 SO 0 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: 1/V0vt.t e <br /> [ ] double compartment OFT VIRONMENTAL QUALITY COMMISSION. <br /> Material: C�1-%(rt F C_ [ ] flow-through I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: Th stem was installed by: <br /> Size/Mat'1 Size/Mat'l I Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth _ I I Distribution I I Plastic DEQ CertificL <br /> on Number: <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model P F 3<v CJ,s I 1 . ('(e''C Q <br /> Pump cycle /( i‘ <br /> times in minutes: on off Gallons per Cycle Company na : <br /> ATT Make and Model (plea.e print) <br /> Attach an additional sheet for components and materials not listed above. Date: 1 <br /> (For Marion Count 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: I Approved I I Approved with corrections: see inspection report I I Denied / <br /> Signed: �� Title: <br /> f[I J (6Z2 Date: IS <br /> Ma: <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:A Forms\Septic AS-41 As-Built2015 Version2017.doc WHITE::Marion County; YELLOW:Ouner:PI.N'K:Installer <br />