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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. 5 9 --Z-3- 0°L.-7ig- <br /> MARION ^ <br /> COUNTY http://www.co.marion.or.us/PWBuildinglnspection SITE AD—D—RESS: .x�.���L I EZ ,,-�t�� �,t <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: !"D 10.4.4..t, 0)2. 4`73o _ <br /> Scale: 1"= _ '(' <br /> ''Le North <br /> o SW <br /> pn4#{_ <br /> -4. ) A- <br /> le <br /> 6F -Z41t ` - - -- - - _ - - _ _ `�I <br /> ,r4-0 Zoo 0 Fem.K.C (2 - 701 E <br /> pJ" <br /> W <br /> In`'^ y'IYitII,G <br /> } <br /> (show all details and dimensions necessarx to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> j k � ,� I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow Gallons/Day r STALLED AT THE ABOVE ADDRESS WAS CONSTRUCT ED IN ACCOR- <br /> TANKSize: 3 total gallons [ I single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer <br /> 1 � 1�Q double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: 171 c [ 1 flow-through VI 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 H PC/L Size/Mat'l 'I Pve- [ I Property Owner(permittee) <br /> (kJ'Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) E y <br /> Rock and under pipe 'krS / ( I�P [ 1 Concrete DEQ License Number: O �� <br /> Pipe total depth [ 1 Distribution [ I Plastic <br /> DEQ Certification Number: a <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage — Trench Depth Minimum — Maximum — <br /> Curtain Drain Depth — Signed:_ <br /> Effluent Pump: Pump Model — . <br /> Pump cycle //�� (�,,"� /7 / � <br /> times in minutes: on off — Gallons per Cycle Company name:_ C eTts-x. �G�.lri— d-D,-rz... Li. <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: I a.-I q-Z1 <br /> f For Marion Conn se 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 I J Approved with corrections:see inspection report I I Denied <br /> Signe-Z/2l��l`— Title: SN" 1n:3 4'}g Date:()I/CD,fa.y <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County:YELLOW:Owner;PINK:Installer <br />