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iiimMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NESA (to be completed by system installer) <br /> 5 3-88EM OR 97305 PERMITNO. 3—C.;' Z1- 001715 — PhAT 100 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection p� <br /> SnE��DDRESS: ���/t 'I-I li,����L/r/ re <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: � � Ott <br /> Scale: 1"= /Vp' SCer. <br /> p� P1 `pAS North <br /> N et, <br /> a -L _ y► c�Q�• 0G �o. <br /> e -D 87 J e !re.v./- Q v40 �N'+�,\,,, <br /> _' ��,�� Z 5(hie-, pL��,e_ D <br /> 0 <br /> e. ;j4r4- <br /> S o <br /> 3 0 s0)•," <br /> .0 ® r 4-4-nl< <br /> z 4. va )isoo 01 h <br /> I4,11 4,14 <br /> t <br /> 10 OtT �®'' G 'j , h <br /> :a B,..„ <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 /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage`� Flow L�� Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANKSize: el,y9 �10p total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> J OF THE ENVIRONMENTAL QUALITY COM ISSI N <br /> Manufacturer: OL,,,`J. V,,'f) I)t�doublecompartment 4-cnl4 Q N4 ,�',,` � <br /> Material: Core re*, [ ] flow-through III have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'l Size/Mat'l I I Property Owner(permittee) <br /> I .Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe n ' pti-Drop �Concrete DEQ License Number: 1111 p <br /> Pipe li <br /> total depth_ Z I I Distribution I I Plastic <br /> DEQ Certification Number: 8�.5. <br /> Drainfield Material(Alternativeor perf.pipe) <br /> Total Drainfield Footage 3 r✓/0 Trench Depth Minimum Maximum_VI ���)� <br /> Curtain Drain Depth /VW- Signed:_ (31"OlQ/1 <br /> Effluent Pump: Pump Model evf 0-1-41; <br /> Pump cyclem GeMk 1 V <br /> times in minutes: on off Gallons per Cycle Companyname:_ e &-1/44-.h 5 <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: if; 2,6 <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: INkAppr ed I I Approved with corrections: see inspection report I I Denied <br /> Signed: Title:DIA2. Date: a <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20 I 5Version2017.doc WHITE:Marion County; YEL1t5NK:lnstaller <br /> W: vner <br />