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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> di, <br /> 5155 Silverton Rd NESALEM (to be completed by system installer) <br /> 5 3-88 OR4 97305 PERMIT NO. ss 5ti al -t9 `'l0 6— �r <br /> MARION I <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection rJ <br /> SITE ADDRESS: t Daa E No�.�e�r,'�k Lei! .$'�' <br /> L) _ <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: O rl s 0 aL 9�3S 0/ <br /> Scale:1"_ T <br /> North <br /> 1901-I-5 P-o;-1i LA] <br /> - ''''. r [:::' . . <br /> r 1 '1 4 G <br /> lu hk o-k L'orrecf- <br /> 1 kA.-fz, L,r veIs <br /> I7. <br /> -� � ' cr 0 <br /> _, --,, T6.4nic 7\ H-A.,,N.,„ <br /> .....,,,,. <br /> C1ea opt' <br /> DOW G <br /> r <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 jar Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: ' fa total gallons 04 single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> ManufacturerI have tested the septic tank and certifyit to be watertight. <br /> Material: �ICa,Srf(1 [ ] flow-through � P <br /> Effluent Sewer: �a Header Pipe: The system was installed by: <br /> Size/Mat'I L/ tii rbph,. Size/Mat'I pc0s' •[,Property Owner(permittee) <br /> [ ] Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) j <br /> Rock and under pipe 91640- I J Drop I I Concrete DEQ License Number: 13 <br /> Pipe total depth DoLDistribution Plastic DEQ Certification Number: j4 <br /> Drainfleld Material(Alternative or perf.pipe) <br /> Total Drainfleld Footage 'I-+ I Trench Depth Minimum Maximum` �/ ii I <br /> Curtain Drain Depth 1 a Signed: /1'14_1 i V 44---...- <br /> Effluent Pump: Pump Model <br /> Pump cycle 11 n /v <br /> times in minutes: on off Gallons per Cycle Company name: C4-n )S IA-1—C.— <br /> ATT Make and Model lease print) <br /> Attach an additional sheet for components and materials not listed above. Date: `'r <br /> (For Marion County��se Only) " e ...•- eptic system has been inspected by Marion County. Th information has been determined to be accurate <br /> and the sy tern is: [4 Approved . [ ` p•A oved with correction : see inspection report [ 1 Denied <br /> Signed: ►✓�\V.c-e a Title: T & JO I -1-7- Date: i 1 (' <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELL W: ner; INK.:Installer <br />