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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> iiiiii <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> �j <br /> 503-588-5147 PERMIT NO. 5-55-22-biPS® a(a — 1 Q 1 - 01 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection /� i 5 y. ,QO a- <br /> SITE ADDRESS:Lai Glo � D t --ro ,o,e <br /> c 312 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= T <br /> P North <br /> 5 <br /> - e <br /> Ft45` <br /> - !, +� C -1) - 3/ I <br /> 1 _F _ t6.:6 t1 <br /> 3 <br /> A- �. <br /> II 12. <br /> Iii <br /> vct <br /> at ° <br /> MS <br /> o 11/ <br /> d 1` <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 /> 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: total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through [ I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: e r Pipe: The system was installed by: <br /> Size/Mat'I S • at'l `Property Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth . clye _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 <br /> DEQ Certification Number: <br /> Drainfield Material(Alt • or erf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum n^ ,A� <br /> Curtain Dr n D p Signed: d `�A°�I . - ' <br /> Effluent mp: u Model <br /> Pump cycle n_` <br /> times in minute n off Gallons per Cycle Company name: �' r 1,• <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: <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: Approved I I Approved with corrections: see inspection report I I Denied JTitle: 4 1 f d�2 Date: ft C <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-BuiId015Version20l7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />