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MuMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM;OR 97305 c g7 <br /> 503-588-5147 PERMIT NO. a3- ��' - 7 7 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection 0 0/ btplr��;�. bp,' • <br /> SITE ADDRESS: <br /> AS-BUILT PLAN OF.CONSTRUCTED SYSTEM: <br />. Scale: 1"_ I 'IS' _6/ c o ti` T <br /> ~WmAi ip North <br /> • <br /> B-t1; 2L I 15 box. <br /> -� = 11` E <br /> s�. <br /> • Er- _ 1® , 111 � � I- <br /> F -C 11ti . , 5� <br /> 1 i' 1s ' <br /> al i C)6 <br /> \) <br /> en <br /> c\G` <br /> I' 11:• . 10 <br /> I '0 Pk . <br /> m <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- <br /> System Design Sewage F,,loow,, Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: i COD total gallons [ ] single compartment DANCE W1T1-1 THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> " " double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> 1i <br /> Manufacturer: VAAAtO <br /> Material: C,inv ,e. [ ] flow-through ',kJ 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'I r J P�C Size/Mat'l q �0�11 roperty Owner(permittee) • <br /> 1 ] Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe / ?Drop oncrete DEQ License Number: c9 �� <br /> Pipe total del) I 1 Distribution I I Plastic ��''� <br /> t DEQ Certification mber: / 7 <br /> Drainfield Material(Alternative or perf.pipe) '�� j/ <br /> Total Drainfield Footage Trench Depth Minimum°°p/-fMaximuir <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model r 73L-S • • <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: / Cer"..Ch—VC"-h 0-v <br /> (please print) <br /> ATT Make and Model <br /> Attach an additional sheet f c mp vents and materials not listed above. Date: / �o Z3 <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: jel Appr ved <br /> I i Approved with corrections: see inspection report I ] Denied <br /> Signed: .ve V Title:J j Date: 7/2/a <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built20l5Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />