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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 251 <br /> 503-588-5147 PERMIT NO. 555 S25—M <br /> MARION <br /> COUNTY htt //www.co.marion.or.us/PW/Buildin Ins ection -� T � t <br /> p' g p SITE ADDRESS: 3 7tJ V fi��./i.a��- l.�'t' <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ T <br /> North <br /> C) Cf" <br /> • <br /> s. <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 WOO gallons Mat'I CoAc,rr.1-e. Mfg DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size gallons Mat'I Mfg I <br /> i pQ I have tested the septic tank and certify it to be watertight. <br /> ATT Make and Model AY Box(es): <br /> I I Distribution The system was installed by: <br /> Effluent Sewer:Size 149 Mat'l I I Drop I I Property Owner(permittee) <br /> I - ' l I Concrete <br /> Drainfield Pipe:Size i/i,it }n, v I I Plastic ( Licensed Sewage Disposal Service <br /> Material:Header Pipe 1 b IEI'' Perforated Pipe DEQ License Number: <br /> Total Drainfield Footage 136 Trench Depth Minimum ice Maximum '3b�t DEQ Certification Number: 1 Z Beg <br /> Rock Depth:Total Under Pipe Curtain Drain Depth <br /> Signed:_ <br /> Alternative Drainfield Materials <br /> Effluent Pump: Pump Model is- Company name:_ Olr%P - <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. <br /> Date: i\ 1-2- 1�3 <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 /> ['QiApproved [ ] Approved with corrections: see inspection report I ] Denied <br /> Signed: 644 akigiOrt Title: E(f JJ 10 ` 'eR - Date: a ol, <br /> MC:S-41 rev:3/03;4/12;5/14 WHITE.•Marion County; ELLO :Oi ner;PINK:Installer <br />