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MeMARION 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.4J� -'f).-Z.—4cYZYC)WMARION <br /> COUNTY p�, y� j <br /> http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: O V k C Ff ee�o� <'tl 0 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: efi ef- od <br /> Scale: 1"_ T <br /> ta' North <br /> • <br /> • J <br /> • <br /> • <br /> %.Te.g Al -1.h<fle3g <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 /> DesignSewage146' O Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System `` Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1 v 0 b total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: St)f;L'r1/410 <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [3g flow-through I I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: b Header Pipe:i The system was installed by: <br /> Size/Mat'l . vr `I. Size/Mat'l H I I Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) 9 / <br /> Rock and under pipe E Z Fib W I I Drop I I Concrete DEQ License Number: <br /> Pipe' total depth 1141 Distribution [}1(Plastic <br /> DEQ Certificati Number: _LI 4 /(7 <br /> Drainfield Material(Alternative or pert*.pipe) E Z Fr-ow <br /> Total Drainfield Footage Trench Depth MinimumAl Maximum a <br /> Curtain Drain Depth Signed:�� Signed: <br /> ffl Euent Pump: Pump Modell, <br /> � . <br /> Pump cycle (- t 1 r <br /> times in minutes: on off Gallons per Cycle C pany name: A 7 7 <br /> 7 <br /> (ple/ease pr•int) I <br /> ATT Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: <br /> (For Marion Conn v Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: ['4►pproved I I Approved with corrections: see inspection report I [ Denied <br /> Signed:Atiat, af2Lke Title:' J't f Uf - \�� Date: 0 t op.:9MC:S-41 rev: 03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELL W:pPINK:Installer <br />