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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 /> - $ALEM OR 97305
<br /> 503-588-5147 . , . PERMIT NO.
<br /> MARION - " .
<br /> COUNTY
<br /> _.;•,,• http://www.co.marion.or.us/PW/BuildhigInspection :: -SITE ADDRESS:
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<br /> ..2i AS-BUILT PLAN OF CONSTRUCTED SYSTEM':
<br /> Scale:.1"---• ' .,
<br /> North
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<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 /> , I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- - •' 4Stern Design Sewage Flow 6. 'LIZ; Gallons/Day ' ' •' STALLED AT THE:'ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR-
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<br />:.,'.. T'ANK Size: t%7:.%5 4.1., , total gallons [ I•single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AD THE RULES
<br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. ci,!'
<br /> ' Matiufactiirect 4 [1.4double compartment
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<br /> Material:P .re5 e.-'Yr kr.. - , [ [ flow-through I I I have tested the septic tank and eertifY it to be watertight. ,. .
<br /> Effluent Sewer, % / 0..,: .z. Header Pipe: , The system Was installed by: _ . .
<br /> i i /Mat'l LI 1:' ' . ' ' [ I Property Ori,ner(permittee)
<br /> [ I Licensed Sewage Disposal Service
<br /> DRAINFIELD rock depth(inches) Box(es)
<br /> - Rock and under pipe Fs'.1.--)---,ieki XDrop ')''.,:<-,..pncrete DEQ License Number:\
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<br /> e Pin
<br /> . total depth . . [ I bistribution 7 I [Plastic 'S .
<br /> DEQ Certification Number:
<br /> DrainfildMaterial(Alternative or pert'.pipe) -
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<br /> Total Drainfield Footage IR 6 Trench Depth Minimum/5 Maximurn_Z_I •
<br /> 4,- — 41 ,--- ...---
<br /> Curtain Drain Depth , ,y: Signed: ,...-,-9,---"----":----- _,..,r--
<br /> Effluent Pump: Pump Model [46 ) c 5 . : .... ,.:, . - .
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<br /> Pump cycle / 1--,v•• r.....
<br /> times in minutes.: on off Gallons per Cycle - - 7*"63..--mPany name:„2 n, J ,..ir x(-4 Lill /7c;?4,/ ...!1_C._
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<br /> i ,,,. • r (i)lease print) 'Y
<br /> '.: • ATT Make and Model !jet ifieC rt CA(:)r) 5,figolaji. 6.ge.4
<br /> Attach an additional sheet for components and materials not listed above.Tia.370.e . Date: •
<br /> (For Marion County 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:j# Approved I I Approved with corrections: see inspection report I I Denied • ,
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<br /> Signed..., :•e,/, 1 Title: g, r,-;77,-/.5 , . , :
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<br /> Date::: ./0 /.9,6",
<br /> • MC:S-4 I rev:3/03 4/12;5/14;1 1/17 G:\Forins\Septic\S-4,1 As-Built20 1 5 Vers ion29 1 7.doc 5 : ' 5 WHITE Marion CounliY,..:YEI,1,01tVivho;PINK Installer
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