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AmMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NESALEM OR97305 (to be completed by system installer) <br /> 5 3-88 PERMIT NO. 55_5 _02 a----00 9 f O R -P F(M y <br /> MARION <br /> COUNTY p://www.co.marion.or.us/PW/Buildinglnspection @ <br /> ' <br /> htt SITE ADDRESS: ,�� �C(,YII b{e sr: X! pprfat\i- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=,,Z6' T <br /> . North <br /> 2: <br /> k <br /> r <br /> <---025- --� c <br /> i per, <br /> �`. .20, SeePQ9 - �a i'" <br /> i p -,o3r <br /> /3„24 <br /> ,.,%.c <br /> 0 <br /> :6 ! <br /> \}, , . <br /> T - To Qked House -j <br /> < t'/ ----). o " o <br /> r. <br /> 4- <br /> , 4 <br /> PA: <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-3 7-.5 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> TANK Size: 1 5 CO total gallons <br /> Manufacturer: p <br /> 'lv_`Ai°re IX double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: t OC)C(eTf [ ] flow-through 4 1'•have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: y Header Pipe: p The system was installed by: <br /> Size/Mat'I I Av�2 s Size/Mat'l i )QP'/e I I Property Owner(permittee) <br /> [:icensed Sewage Disposal Service • <br /> DRAINFIELD I rock de r I depth(inches) Box(es) <br /> Rock and under pipe i flea I I Drop I I Concrete DEQ License Number: 388 7 <br /> Pipe total depth I I Distribution I I Plastic /) / <br /> Drainfield Material(Alternative or perf.pipe) <br /> i+ DEQ Certification Number: ,. / <br /> Total Drainfleld Footage Trench Depth Minimum N axin .-n <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model ®i�;ry,O to ? 'oc?S 1 1 T <br /> Pump cycle s G 1t, , ��c. / L C. <br /> times in minutes: on off Gallons per Cycle Company name:_ A- • L <br /> (pleas print) <br /> ATT Make and Model � �2 6 � <br /> Attach an additional sheet for components.and materials not listed above. Date: / • <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 systemstl <br /> is: [l AApproved [ I Approved with corrections: see inspection report [ I Denied <br /> Signed: � Title:et-kW Date: (X/ <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-BuiIt2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />