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1 <br /> iiiiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. 3SS-D:5-WS33-S'- nPO-- <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 34(,0 suw,n,sQr-S L.,,, SE <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ,,--'"-- T <br /> S.3MtrxJ5 '1--"-' l North <br /> 6rv.vtA ?rt oe.a <br /> 2s, <br /> Z s. ,0 NNN• <br /> \ ��5 y ' <br /> ���� aRC,*;ninj <br /> tNikki <br />, 14)1" <br /> \ . 4\' IE .c I v-t.,,k <br /> *) 'V <br /> Q) <br /> 9:5‘.....,.... <br /> H- <br /> N <br /> Netails 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 /IAD Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: UN total gallons [ I single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> �/►)t)vk- ` [ double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: (f3iNC.re L . [ I flow-through [ I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: _ Header Pipe: T system was installed by: <br /> Size/Mat'I `)-. 1 VL. Size/Mat'l roperty Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum G„_ <br /> Curtain Drain Depth Signed: <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date:_ <br /> (For Marion Count 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: [✓ �pprov I [ Approved with corrections: see inspection report I [ Denied <br /> Signed: ,�'J Title: -�SA \Qg- ` ` ' Date: i 1�1'aoa` <br /> MC:S-41 rev.3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PI K:Installer <br />