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, <br /> .' MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> dili <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. les'5.-73 -oe c 70 .. ()Km r <br /> IIIARION <br /> COUNTY B http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 760 E er,,,te Vtel/ 4 vG <br /> Ne. <br /> BUI,,T P+.AN OF CONSTRUCTED SYSTEM: <br /> 1'' _ 39' /1r6 vc[l Ci 1.+cit/. • T <br /> North <br /> 20 <br /> 13 <br /> V <br /> 5 g,,,c.es e� ti`\,\ <br /> 4 P <br /> c_ 2ti° <br /> Q- C 33, �'a \"��6) <br /> 39 <br /> cp <br /> # — 0 c <br /> LP�Q�'S <br /> Q-p , <br /> I0' ISM <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: I INSTALLERS CERTIFICATION: <br /> y DesignSewageADO Gallons/Day f 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 G®v total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: �e-i t s <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: f c/ic-t s'" [ ] flow-through IA I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: I I The system was installed by: <br /> Size/Mat'l -telln ,p„.11 Nu Size/Mat'I 4 3�a 1 I I Property Owner(permittee) <br /> [A Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) 7 <br /> Rock and under pipe 211 I).Drop ()}.Concrete DEQ License Number: 1)4 6 Q <br /> Pipe total depth 3 0 I I Distribution I I Plastic <br /> DEQ Certification Number: a 3S <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage 1. •5 Trench Depth Minimum bI p Maximum LI Z � � <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model / . <br /> Pump cycle _ <br /> times in minutes: on off Gallons per Cycle Company name: Vc-/A i( E rtr <br /> (please print) <br /> ATT Make and Model <br /> ___al (f <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: [ proved [ I Approved with corrections: see inspection report I I Denied <br /> Signed: Title: — 1 1O1 9 Date: 067-2C hil-A <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41`As-Built20l5Version20l7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />