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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 /> SALEM OR 97305 <br /> - 503-588-5147 PERMIT NO. 2 3 -'(jr ' � <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: / (f-54:76— LI-41l11 <br /> 1S <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=_' <br /> North <br /> /do do <br /> .tb <br /> • <br /> • <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 /> • <br /> System Design Sewage Flow Z .- Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM f�� IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /COM V total gallons [single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: t�V�lJ�u�LA..)�. [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: Lt r wa:— [ ] flow-through PI I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: 1% Header Pipe: The system was installed by: <br /> Size/Mat'l ') S C 1 t-1 Size/Mat'l N 27 2-/ I I Property Owner(permittee) <br /> i>f Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe Drop I I Concrete DEQ License Number: ®C <br /> Pipe total depth I I Distribution perPlastic {� <br /> DEQ Certification Number: ACE <i`a <br /> Drainfield Material(Alternative or pert.pipe) .D C..SY749%""" <br /> Total Drainfield Footage Trench Depth MinimumWl Maximum (q <br /> Curtain Drain Depth Signed: �. <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> • <br /> times in minutes: on off Gallons per Cycle <br /> Company name:_ e>��.� ��� .��(;�-� L g <br /> ATT Make and Model (plealse print) <br /> Attach an additional sheet fo omponents and materials not listed above. Date: .5—/` .� <br /> (For Marion Coun se Only_l_The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: ( Approved [ I Appro with corrections:see inspection report [ l Denied Q <br /> Signed: Title: i S1- 10a Date: d (� <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-4l As-Built2015Version2017.doc WHITE:Marion County;YELLOW::Owner;PINK::Installer <br />