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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. 5 3 -t35 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 3 7..0 C.4 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= T <br /> North <br /> • <br /> eit <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 /> 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 PSOO gallons Mat'1 e-r.+t Mfg (A)4,-+{--e. DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size gallons Mat'l Mfg <br /> 1 I have tested the septic tank and certify it to be watertight. <br /> ATT Make and Model AA' 70 Box(es): <br /> I I Distribution The system was installed by: <br /> Effluent Sewer:Size Lill Mat'I O .' ) __ I I Drop ( I Property Owner(permittee) <br /> l8 , ti ( ]Concrete Licensed Sewage Disposal Service <br /> Drainfield Pipe:Size 6 ��l I ]Plastic <br /> Material:Header Pipe ?IC. Perforated Pipe g 2 FIN.) DEQ License Number: <br /> Total Drainfield Footage i35j f Trench Depth Minimum I` " Maximum 3J`/ DEQ Certification Number: ZpCj 3 <br /> Rock Depth:Total Under Pipe Curtain Drain Depth <br /> Signed: <br /> Alternative Drainfield Materials n <br /> Effluent Pump: Pump Model f F '50 Company name:_ D1-A'd-"N ca�S�N�— t;r1 <br /> Pump Cycle minutes minutes (please print) <br /> Time on off Gallons per Cycle <br /> Attach an additional sheet for components and materials not listed above. Date: t t z /Z'j <br /> (For Marion County Use Only) <br /> The above septic system has been inspected by Marion County.The information has been determined to be accurate and the system is: <br /> Appro ed® [ ] Ap ed with corrections: see inspection report I ] Denied <br /> igned: Title: a Date: <br /> MC:S-41 rev:3/03;4/12;5/14 • WHITE:Marion County, YEI: Owner;PINK:Installer <br />