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•s-•J <br /> INDIVIDUAL ON—SITE SEWAGE SYSTEM RECORD <br /> MARION COUNTY BUILDING INSPECTION (to be completed by system installer) <br /> DIVISION <br /> COV NTY 555 Court St NE/30 Boa 14500 I S I �w S�4 S-� C A.,�5 Of <br /> Salem,3)O 95-5147 36 <br /> (503)588-5147 SITE ADDRESS: I <br /> PERMIT NO. 0✓ - 0 Mci 3 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> scale: 1" _ <br /> North <br /> j #p <br /> CFI o ik C/ r, <br /> • , <br /> ,,, <br /> ..... _ _e - I W <br /> oks r <br /> 1 ) An9 7', <br /> � v �- tit 1 <br /> _c 4 <br /> 0 <br /> .1, <br /> _ A -C = 52 �Go�� ear° ' f �,t i c� S7% <br /> 6 _c 2G-' C- —t ' 90 ' (T A & 5, / <br /> A - t.- � 3?1g" B - C = 251 — F - D — 5S <br /> A - o - 58' A -C = 5-'61' F _ E = 65'I <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 /> System Design Sewage Flow: GGG 450 Gallons//Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br /> SYSTEM Septic Tank: Size: I� C1ui Nat'l: CQri'�('lpi Mfg: ( STRUCTEDNINA ACCORDANCE LLED AT EWITH VTHEDREQUIREMENTS DRESS WAS NOF <br /> [� r ` �{ 1'�' THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br /> Dosing Tank: Size: .IaU0 Qfii.1 Mat'1: �(1['Q(��y Mfg: .1TE.- QUALITY COMMISSION. <br /> /� <br /> [ ] I have tested the septic tank and certify <br /> Effluent Sewer: Size: '1 Mat'1: Asrr� 2 1,J`I 1 it to be watertight. <br /> Box(es): [ 1 Distribution: ( ) Drop / ( I Concrete; ( ) Plastic The system was installed by: <br /> 4 [ 7 operty Owner (permitee) <br /> Drainfield Pipe: Size: C� ; Material; Header:?l(Q ASLItel, �L Licensed Sewage Disposal Service <br /> 6,1 3`1obc <br /> Total Drainfield Footage:; Rock1A�' Depth: Total, 1� Under pipe: DEQ License <br /> _�Number: <br /> /��a��� <br /> Alternative Drainfield Materials: IY ,^ / Iy'�_"_ <br /> pp 11 ^^ 1i � Signed <br /> Trench Depth: Minimum: 'p ; Maximum: e�la Curtain Drain Depth: N- ,� M ,l' <br /> Effluent Pump: Pump Model: ME 40 Static Head in System; _ \.tjFL. Company name: 'L.( 5 e t- L'Q cC k_I <br /> (please print) <br /> Pump Cycle Time: f-1 .1. ; Gallons per Cycle: h <br /> 31 O Date: 8— — O`(Y <br /> Attach an additional sheet for components and materials not listed above. <br /> (for Marion County use only) <br /> The above septic system has been inspected by Marion County. The information has been determined to be accurate and <br /> system is: <br /> Approved <br /> [ ] Approved 'th correct' n : e i pection report <br /> [ I Denied {(1[ r1 <br /> Signed: Title: ``E 14S Date: �19 -O W <br /> MC: S-41 WHITE:Marion County; YELLOW:Owner; PINK:Installer <br /> rev: 8/00,6/01 <br />