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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. s-S .S Z I — 00 7 7S kl <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection SITE ADDRESS: Z��� N©>� 1.'p rlL <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> ale• 1"_ r.`.,_pi, f . -r - • _ T <br /> p. �* 3 t:: <br /> , <br /> acarl�e: 1" = _� n�1 _0 Non North <br /> '( s3' II -. <br /> /a I <br /> keg1114 1, 9a — _ , ... <br /> zipG '"" 8 ' — <br /> ir;.1 S'' '� <br /> 90 <br /> ...0V,* <br /> Lie i <br /> t . s . <br /> kk,e,?\,:%-r-,e_S F <br /> mil( Gl'a )0✓'° f� S� Q �M <br /> 1 • <br /> �N - is i s Lt,h .E R040r s 10 ere w,zouea <br /> 1 <br /> : \ <br /> II h a - as keist ct.c,ei 3 oxits <br /> D ! --:'. 147.44? (k..4.:›1 acc- 2-e- I ° -1-- <br /> .� ‘ , ‘-`- <br /> Lira fo C; _ » ' EXPIRELt <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 [ 1 single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> [ ] double compartment <br /> Manufacturer: <br /> Material: [ ] flow-through I I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'I Size/Mat'l I I Property Owner(permittee) <br /> 0 Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe Drop I I Concrete DEQ License Number: 3�Ue7 <br /> Pipe total depth I I Distribution IXPlastic 7 <br /> DEQ Certification Number: 2-15 <br /> Drainfield Material(Alternative or pelf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum <br /> Curtain Drain Depth 0/ Signed:_ `� <br /> Effluent Pump: Pump Model �/f a✓L.. I <br /> Pump cycle • <br /> times in minutes: on off Gallons per Cycle Company name:_hp'-'--i.e _4. _`.r� { ` C 5 <br /> ATT Make and Model <br /> (please print) <br /> 2—Attach an additional sheet for components and materials not listed above. - Date: ! — f ,;'"1, <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: [ J Approved [ I Approved with corrections: see inspection report [ I Denied <br /> Signed: Title: Date: <br /> .-MC:S-41 rev:3/03;4/12;5/14; I1/17 G:\Forms\Septic\S-4I As-Built2015Version2017.doc WHITE:MarionCounty; YELLOW.Owner;PINK:Installer <br />