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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 /> 503-588-5147 PERMIT NO. S S S-D 3 - CS C)s t 5 <br /> MARION <br /> COUNTY htt //www.co.marion.or.us/PW/Buildin Ins ection <br /> P� g P SITE ADDRESS: 1 7,3 c-I5 W c.....-a. 1—✓, <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=3O' T <br /> North <br /> 6L►a Q _ <br /> TOtSoa. —p DI y <br /> L 1 <br /> . t <br /> o <br /> ovse o- <br /> .? I - , _l , <br /> to— <br /> 4.a v <br /> .-, o <br /> am.' ; 'o- <br /> .. a <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: V <br /> System Design Sewage Flow s 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: I.SOO C►0co15-C41 gallons [ I single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <(r.. <br /> double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: C_O v►CCt�Ne.- [ ] flow-through WI have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'I �'‘ S GLa tto Q 0 C- Size/Mat'I 1a.7114, [ I Property Owner(permittee) <br /> [)(Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe CZ)" '- _ I I Drop I I Concrete DEQ License Number: 37 cLO63 <br /> Pipe total depth la-l¢, I I Distribution I I Plastic DEQ Certification Number: /?...1.&30 <br /> Drainfield Material(Altemative or perf.pipe) <br /> Total Drainfield Footage L.60 Trench Depth Minimum l b Maximum DA <br /> c <br /> Curtain Drain Depth A.) A Signed._ <br /> Effluent Pump: Pump Model 1,z 10.tt47 &3 . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle ? t) Company name: q. gio T G- <br /> (please prin <br /> ATT Make and Model A.),6. <br /> Attach an additional sheet for components and materials not listed above. Date: 7- c 7-"D--(4,_ <br /> (For Marion County a Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [- Approved l Approved with corrections: see inspection report I I Denied <br /> Signed: Title: 4-51. ICTL2-1259--? Date:1-1131-Z,cl <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />