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' ' MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> iiihi <br /> 5I55 Silverton Rd NE 97305 (to be completed by system installer) { . <br /> 5 3-588- 14SALEM OR PERMIT NO. S55® 2 — 0®""1((2 I— Mtn ` <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS:l O 11-ail Po( L r S S�1 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: C:1-1� <br /> Scale: 1"_ 40' T <br /> North <br /> kW <br /> iql <br /> 4 Oil <br /> In <br /> I <br /> shoe • 79 <br /> I cm <br /> / . -=TAartk <br /> cio.� �� <br /> , ,• <br /> I <br /> . . <br /> 11414 P <br /> / <br /> T (.. <br /> / K etAS 1_, <br /> ,.. <br /> -L, <br /> ,, , <br /> t' <br /> v,. . <br /> - Lkic,it . eir <br /> (show all details and dimensions necessary to locate all components olthe system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> y DesignSewage ��� Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: II 0%9 total gallons X single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> l-,-T�±Dr [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: rr'1 <br /> Material: PG1y p1 C: [ ] flow-through XI have tested the septic tank and certify it to be watertight.. C <br /> Effluent Sew�erp:I o /�I� `_ Header Pip : `Y The system was installed by: 1 W M elATV&Gk l:Sf vA l\ves <br /> Size/Mat'I -1 1-�� SCj �� Size/Mat'l � \j(- j®.� Nxi Property Owner(permittee) 'kjO tti " 0 lam' <br /> I Licensed Sewage Disposal Service4,,,,,,,,,,ty <br /> DRAINFIELD rock delt(inches) Box(es) <br /> Rock and under pipe Drop I I Concrete DEQ License Number: <br /> Pipe total depth I2- '~ I I Distribution (,Plastic <br /> �°°4DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) -1 Pv Pe... �` <br /> Total Drainfield Footage� `' �� Trench Depth Minimum11 Maximum <br /> Curtain Drain Depth_ ^I J'/'- Signed: CP' <br /> Effluent Pump: Pump Model N 0 i - <br /> Pump e /I p(� r y, dal(e b <br /> times in minutes: on off Gallons per Cycle Company name: , I.11� <br /> ATT Make and Model N/ y (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 1 6/ S <br /> (For Marion Co n y 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 [ ] Approved with corrections: see inspection report [ ]Denied <br /> Signed: ` Title: 17-1;>c Date: (j v 2-? <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YEL OW:Owner;PINK:Installer <br />