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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 /> MARION 503-588-5147 PERMIT NO. 2 3 —[ j `\3 <br /> COUNTY hftp://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: / J-tSo� w77,4,cl.o, �i�s (,1,A-{1‘ <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' T ' <br /> North <br /> • <br /> 749 <br /> -1 b ` <br /> \ • <br /> sir 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 `��S Gallons/Da I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> y STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /CCUs1D total gallons [single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer. ��t t � double. [ ] compartment <br /> Material: Ca—cL [ ] flow-through (x]I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: t ti Header Pipe:« The system was installed by: <br /> Size/Mat'l �} 5 V S t i Size/Mat'l H .7 _dj ] ]Property Owner(permittee) <br /> I>f Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Concrete DEQ License Number: <br /> Rock and under pipe Drop r. �7P�� <br /> Pipe total depth l 1 Distribution l(Plaslic <br /> DEQ Certification Number: c _ 'jI (-j <br /> Drainfield Material(Alternative or perf.pipe) or e._tj;5"""" <br /> Total Drainfield Footage Trench Depth Minimumg Maximums(r <br /> Curtain Drain Depth Signed:Effluent Pump: Pump Model <br /> Pump cycle <br /> • <br /> times in minutes: on off Gallons per Cycle Company name:_ J``�� \��_ g-�p't� L g <br /> ATT Make and Model (plee print) <br /> Attach an additional sheet f omponents and materials not listed above. Date: ` /�'-'Z <br /> (For Marion Coun se Onl The above septic system has been inspected by Marion County. The information has been determined to be accurate i <br /> and the system is: [ Approved [ I Appro with corrections:see inspection report [ I Denied G� 1 <br /> Si ed: Title: CrAA 5 V `01iT 9-3 919 /Date: I-I/ <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WIHITE:Marion County;YELLOW.Owner;PINICInslaller <br />