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1VIARION 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. 555— a a- q{19 1- r RMT— 01 / <br /> MARION <br /> COUNTY � Ni 9 E. � ` <br /> http:/lwww.eo.marion.or.uslPyb7BuUdfnglnspectlon SITE ADDRESS: Cls�P `V <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Aurora oR q-100Q <br /> w T <br /> ,i.six North <br /> 1800 yat <br /> / •t <br /> concrete <br /> �� $5 tank <br /> Coen Nor <br /> Community Church <br /> Neighboring <br /> Building <br /> B-St1=20' <br /> C-SthT ••- ua <br /> B-Dt1.30' on <br /> C-Dt1.52' <br /> A-Dt=71' <br /> B-D1=49' <br /> A-D2=69' .41 <br /> B-D2.48' Ci <br /> A-D3-88'6" Driveway 4 <br /> B-D3=86' <br /> lit ..., <br /> oo _.--4 <br /> r10o rt--1 <br /> Scale <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONSt, INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow 6.a Gailons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 100 CY total gallons Ksingie compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: 1r1 G [ j double compartment OF <br /> r ,,ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: C 49 n.C .'ft- ( ) flow-through a have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The s stem was installed by: <br /> Size/lvlat't Size/Mat'I I 1 erty Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) ( ,,, <br /> Rock and under pipe [ I Drop [ I Concrete DEQ License Number: a'34 �dJ <br /> Pipe total depth [ I Distribution I I Plastic �--,L. pqn <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) <br /> Total Drainfleld Footage Trench Depth Minimum Maximum.__ <br /> Curtain Drain Depth_ Signed: <br /> Effluent Pump: Pump Model L ` 7` ea 3205 . <br /> Pump cycle 7o ` (� <br /> Company name:_times in minutes: on off Gallons per Cycle p y 1M�r\e�n 1 <br /> { <br /> ATT Make and Model `t(please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 1I 1 [ i a- <br /> (For Marion Coun 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 [ I Denied / <br /> Signed: 22 Title: , � �0 Date, 0/ /9-/ �MC:S I rev:3/03;4/12;5/14;11/17 G:\Forms'Septic\S-41 As-Built2015Version2017.doc WNITE:Marion County I W t?warer;PINK:Installer <br />