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4. <br /> INDIVIDUAL ON—SITE ' SEWAGE SYSTEM RECORD <br /> f ' (top be completed:bry system installer) ��^ <br /> SITE ADDRESS;• <br /> `!•5 4 pe e g 4L1 . .`_,A `s'1 i J! QP. ' ""'PERMIT ATO O. )1 A <br /> 07 <br /> AS-BUILT PLAN-OF CONSTRUCTED SYSTEM: . . , _ • <br /> - scale: 1" m ' <br /> ,,.... � � • <br /> North <br /> J • wi„ . <br /> • <br /> $y. N . oil- _ 6 <br /> 's <br /> t. .0 • <br /> niC. Cie:1 I R V ..4. 44 t . <br /> (,show all details and dimensions necessary to:.4tocate all components of the system in.the :future) <br /> • <br /> SYSTEM�LA'$SRYALS AND SPECSPSCATECIE: :'%I INSSALLIMS Ci zTIFxcsrrGMx _ . <br /> •,•i I HERSEY CERTIFY THAT TSN ON-SITE SEWAGE, <br /> SeNtia Teaks Size: ppiolb Met'1: MEG, •' SYSTEM rasTALLep AT SAS ABOVE ADDRESS WAS Cos- <br /> i =WCAED' IN ACCOEIANce PUTS THE REQOIRSMENTSS OF <br /> VasiegtSanks Bizet Mat'L: Mfg: •. THE•PERMI'A' AND THE RULES OF THE ENVIRONMENTAL. <br /> Eifiueut B,wazs Size: Mat'1: Q17AC.iI COMMISSION. <br /> 1 1 I have tested the aeptxo tank and certify <br /> it to be watertight. <br /> i Smaed x 94, Distribution; 1 1 Drop / 16117,0 Concrete:. i 1 WIleseic <br /> •i The system was installed by: <br /> Ora/nets- Sie d Aipa: z : VM ;,Mattriel.; Header: ;,.P rf: Pro rt Owner (pern:Stee] <br /> Pe Y <br /> ' . Total.Dfrelafield•Fao x ilie •; stack .•. �M 1 P p N t 'LSCenseQ Sewage Di9p49A1 Sexv�ee <br /> tap=., Depths Total. ilnrLht i e:'&► <br /> . - Yraaah D.ptht Minimum: i t : Maximum: / ; Curtain Drain:Depth: signed: <br /> wisest Peeq:t.Pump model: ; Static aced in.Systel: it.. i_al► , p) i / <br /> . Company name:a ��"• � <br /> •ii T (please printi • <br /> Pump'Cyele Time.: Gallen., per'Cyp1e: <br /> . xttaiah as addleiaaal aheut for eempenrnta eed matariala anti 1i4:tad above. Date: 1y'�- :)3 _ • <br /> (for MarionCounty use only) • t <br /> .The above septic system has been inspected ,by[Marion County. The information has been determined <br /> . •to:beaccurate and the system is.: <br /> E Approved h <br /> Approved with corrections; see inspection report <br /> l Denied _ <br /> r . <br /> '' Signed: 1 T :tcle: •''��'�"�i 4. Date: Ia! <br /> 'es-bull . rm 4/.95 ' ,W1UTE:Mar.om County; YELLOW:Owner; PXNIG:lnstailer <br /> MC-15-S41 <br /> . • i <br />