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MARION COUNTY BUILDING INSPECTION <br /> 6 !1 555 COURT ST NE/PO BOS 14500 <br /> --- - SALEM OR 97309-5036 <br /> Minim' INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> Cots„ry (to be completed by system installer) <br /> SITE ADDRESS: 9b9A/ /Vi /// (" ,,., iL p� ,S PERMIT NO. 5& -'2 7 6787I262-7 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 1 <br /> Scale: I"_ ' <br /> e , gyp,,/ , <br /> North <br /> • \ <br /> IYvl/ . <br /> J-- t2ti12-C—C)1/4-- <br /> • <br /> . V- lifisb &/ <br /> Ak t_ve) <br /> (show all details and dimensions necessary to locate all components of the system in the future)r <br /> e.-(I <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow: Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> Septic Tank:Size: Mat'I Mfg: DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size: Mat'I Mfg: [j I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer:Size: Mat'I: The system was installed by: <br /> [j Property Owner(permitee) <br /> Box(es): Distribution; j I Drop / m) <br /> Concrete; 11 Plastic Licensed Sewage Disposal Service O� L?\y t7 <br /> Drainfield Pipe:Size: Y" ;;Materir�Qal`:Header: 2-77 .9 ;Perf:13/c•-ciL/py DEQ License Number: 3?474' / (2, 1 Ct l <br /> Total Drainfield Footage:/6/0 ;Rock Depth:Total: I).— ;Under Pipe: 4' <br /> Signed: '—` <br /> Alternative Drainfield Materials: <br /> - <br /> Trench Depth:Minimum:V1 ;Maximum: 3 t7 ;Curtain Drain Depth: Company time:, t...t>v..t i` I L , S ke rY,-..5 <br /> (please print) <br /> Effluent Pump:Pump Model: ;Static Head in System Ft. <br /> Date: I ').„-- _I--2.1 <br /> Pump Cycle Time: ;Gallons per Cycle: <br /> Attach an additional sheet for components and materials not listed above. <br /> (For Marion County Use Only) <br /> The <br /> above septic system has been inspected by Marion County.The information has been determined to b accurate and the system is: <br /> 1 11 Approved ' ^ A 3 e C(I_ �O\ , <br /> ( J Approved with corrections:see inspection report W vv p ,I�V,h'^� <br /> ( 1 Denied • <br /> i_ � EOM <br /> ' r <br /> Signed: 0./YWDerkt 0, . ft Title: L l I W IO1 `-i�'P1,D Date: I d-LIl�,C'I <br /> MC: S-41 WHITE:Marion County; YELLOW.:Owner;PINK:Installer <br /> rev: 8/00,6/01;3/03 <br />