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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 <br /> 503-588-5147 PERMIT NO. ) 6 cl <br /> MARION <br /> -COUNTY- <br /> http://www.co.marion.or.us/PW/BuildingInspection f <br /> SITE ADDRESS: [GJ�.9� W adbu( /1 <br /> '- <br /> veto n,I-et C.o.Lo <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM:-------'-._, <br /> Scale: 1"= 3© .�' Si Cest T. <br /> North <br /> . r, 1 <br /> ...-., <br /> v„,,,, <br /> d�'��� 0. . <br /> l� . <br /> • <br /> 1.59 <br /> (show all details a d dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM/� IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> Septic Tank:Size I`t0 gallons Mat'1 LoAc(LT Mfg0-7a•tf conC f ter< DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size gallons Mat'! Mfg <br /> [ ]I have tested the septic tank and certify it to be watertight. <br /> ATT Make and Model Box(es): <br /> [ I Distribution The system was installed by: <br /> Effluent Sewer:Size Mat'l [ ]Drop [ I Property Owner(pennittee) <br /> Concrete [I Licensed Sewage Disposal Service <br /> Drainfield Pipe:Size f]Plastic <br /> Material:Header Pipe Perforated Pipe- DEQ License Number: 'q(‘W <br /> Total Drainfield Footage Trench Depth Minimum Maximum DEQ Cert. cation Number: Lit Liti(p <br /> Rock Depth:Total Under Pipe Curtain Drain Depth <br /> - Signed: <br /> Alternative Drainfield Materials //� <br /> Effluent Pump: Pump Model Company n e:; k'(ti N.05 (p1 cs}[`yCk4p L(C <br /> Pump Cycle minutes minutes (please print) <br /> Time on off Gallons per Cycle <br /> Attach an additional sheet for components and materials not listed above. Date: .O I <br /> (For Marion County Use Only) <br /> The above septic system has been inspected by Marion County.The information has been determined to be accurate and the system is: <br /> 1 Approved [ ]Approved with corrections:see inspection report [ ]Denied <br /> Signed: Title:A (i Date: OA c <br /> -(1147 <br /> MC:S-41 rev:3/03;4/1 ;5/14 WHITE:Marion County;YELLOW:Owner;PINK-Installer <br />