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t�j4R10NCOUNIY BUILDMGMSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> DIVISION <br /> BUILD1 (to be completed by system installer) <br /> aIOM 555 Court St NE/PO Box 14500 <br /> NMI Salem,OR 97309.5036 I S mac. <br /> I <br /> ,S 4 Si C AT 5 Oil <br /> (503)58S-5147 SITE ADDRESS: r' <br /> PERMIT NO. t/h✓G ' 0 9Aci3 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> scale: 1" _ ) I <br /> North <br /> e p <br /> ilk <br /> t;/'o g. {� <br /> • <br /> C <br /> Jr` <br /> X "7 <br /> °) I Ito 4se111 <br /> ' <br /> - — - - �4' <br /> ...; 4 <br /> b _C L 25 ' C —b = 90 ' (T A A & s. _ / <br /> A , e 37�gi[ Q _C 251 — F - D - 55 <br /> A - = 58 C.. - 6-' %'' F - E __ 15' <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: 4 50 Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br /> .�{, SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br /> Septic Tank: Size: I� (jtr4A Nat'l: CQti�('�Ql Mfg: L0(,(.� 1 L STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br /> �y I �{ THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br /> Dosing Tank: Size: �C) 6 L Mat'l: �oc1t(�„? Mfg: T e_ QUALITY COMMISSION. <br /> f /� �('�� [ ] I have tested the septic tank and certify <br /> Effluent Sewer: Size: p[�t Nat.': AsrM t7�'� 1 it to be watertight. <br /> sox(ea): [ ] Distribution; I I Drop / ( ] Concrete; [ I Plastic The system was installed by: <br /> p ( ] operty Owner (permitee) <br /> Drainfield Pipe: Size: a ; Material: Header: ?V.t 5S deb .Q k License3 Sewage Disposal Service <br /> Total Drainfield Footage:'; Rock Depth: Total: 1 �i; Under pipe: lc" DEQ License Number: 31 0 6 S <br /> Alternative Drainfield Materials:pp�, ^^ t� A. Signed: <br /> NA- <br /> Trench Depth: Minimum: 1 p Maximum:All eY� Curtain Drain Depth: � 'Q dr <br /> Effluent Pump: Pump Model: M€ 40 Static Head in System; „ . k.1j`Ft. Company name: L0XSei-3 B, c <br /> uize <br /> (please print) <br /> Pump Cycle Time: M 1.1. ; Gallons per Cycle: � (�. <br /> 3 O Date: Clx — 8 ` O`f' <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 /> [ ] Denied � <br /> Signed: Title: k� c (Date: ! 1CI —0 <br /> MC: S-41 WHITE:Marion County; YELLOW:Owner; PINK:Installer <br /> rev: 8/00,6/01 <br />