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1 <br /> • 1 . <br /> AN., 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 /> MARION 503-588-5147 - PERMIT NO. ,5 `2`j— (,D?j r <br /> Y: 2 <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection SITE ADDRESS: S 3 7_5 biivivep PpiALt p. 11,1 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: j Sa/e'-"— <br /> Scale: 1"= ' ' -- T <br /> North <br /> `` <br /> t$1 1� <br /> ,¢ f <br /> - <br /> • <br /> ---) <br /> flT <br /> lc, <br /> 1 <br /> c <br /> I <br /> • <br /> - --- ---- - --- 1 — - <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 /> System Design Sewage Flow -.S 2--..- Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size:/09/1. total gallons N single compartment DANCE WITH THE REQUIREMENTS OF1THE PERMIT AND THE RULES <br /> C' double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: /a.3G�/'1�� [ ] P <br /> Material: ele, .c._ [ I flow-through 4 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer 1/I e t Header Pipe: e' The system was installed by: <br /> Size/Mat'I 1 /ki SC t C�&..A1 `)1 Size/Mat'l 2-7).-Qi' 1 I 1 Property Owner(permittee) <br /> DRAINFIELD rock depth(inches) Box(es) <br /> pd Licensed Sewage Disposal Service <br /> Rock and under pipe I I Drop 114 Concrete DEQ License Number: 2 70 C-7i S <br /> Pipe total depth (4 Distribution I I Plastic DEQ g�� <br /> Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) ec.....0 y '�`. <br /> Total Drainfield Footage ade <br /> g Trench Depth Minimum/� Maximum�� <br /> Curtain Drain Depth Signed:_-1 J t--.-- <br /> Effluent Pump: Pump Model ®C,2A apt-5 <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: •-•`'‘...._ 41 L.L. S ilz 3 i-`L-s <br /> • <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: f a—be'-'2-3 _ <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: JAApproved <br /> /}[ [] roved with corrections:A � see inspection report [ ]Denied <br /> Signed: ,� IA • I.l11 Title: �VL) I •_ Date: ' <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Maria:County YEL OW:Owner••PINK:Installer <br />