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iiiiMARION 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. 5 5 5-2 3-O z 1 S 2, <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection ,��/ <br /> SITE ADDRESS: / 3870 L lA 81 /� {1J k <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= T <br /> North <br /> frse zfrtac/hecL <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 si 50 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1500 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: wd;f G tr` <br /> double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: n t9 solar 4 f-e. [ ] flow-through x I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: t1 Header Pipe: The system was installed by: <br /> Size/Mat'l I ''/'/ P4/ 'L Size/Mat'l 31r &cif ' I I Property Owner(permittee) <br /> lift Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) .�/ <br /> Rock and under pipe 4�� I I Drop X Concrete DEQ License Number: 370 b S 9 <br /> Pipe total depth /2" — )ICI Distribution I I Plastic <br /> DEQ Certification Number: _ <br /> Drainfield Material(Alternative or perf.pipe) 3'1 Per <br /> Total Drainfield Footage2te Trench Depth Minimum1_8 Maximum 3b - <br /> Curtain Drain Depth Signed: Vaa <br /> Effluent Pump: Pump Model 0 r en[.0 P,C 3o05 10 <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle t�pm Company name:_ 0 La C:o n s#l c4 e. Iitoh Like, <br /> . <br /> ATT Make and Model (please print) <br /> Attach an additional sheet f components and materials not listed above. Date:J/-3 0-_2-,. <br /> (For Marion Coun Use Only_LThe above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: Appro I I Approved with corrections:see inspectionti report I I Denied <br /> Signed __ __ !tie: LN S-r \n o` 3 V V Date: <br /> MC:S-4l rev:3/03;4/12;5/14: 1 1 17 G:\Forms\Septic\S-41 As-BuiIt2015Version2017.doc WHITE:Marion County: YELLOW:Oirnt'r:l'l.\ti":In.vtallrr <br />