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• <br /> MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON—SITE SEWAGE SYSTEM RECORD <br /> giiiii 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 155 ..4.f.A.1'1c ✓t��� Pri i"` r- <br /> .9---� 4t'�I'" <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: �� . <br /> Scale: I"= <br /> l I l G I North <br /> �ll� I SI <br /> 1 SOO e ,l,j <br /> Wi14-1-0._ I✓4'1 2 I °1 1 Ilk <br /> ( ,S. l✓r r5ec t <br /> l Sc�4 , \o . <br /> 25( I <br /> o <br /> s <br /> a+'Zl9CCc —i-- <br /> f -5 i.e�t 94 <br /> _ (show all details and dimensions necessary to locate all components of the system in the future) _ <br /> SYSTEM MATERIALS AND SPECIFICATIONS: I INSTALLERS CERTIFICATION: <br /> I I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow 37 S— Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I SU& total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: �p; <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: C_p,AC__ _r [ ] flow-through „Q I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: tr The system was installed by: • <br /> Size/Mat'l Size/Mat'l SQL` K0 I I Property Owner(permittee) <br /> Xl Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) 3q /- <br /> Rock and under pipe 3 I� I I Drop I I Concrete DEQ License Number: I�v <br /> Pipe total depth ( Z li I I Distribution I I PlasticO <br /> DEQ Certification Number: J ,?j C <br /> Drainfield Material(Alternative or pelf.pipe) <br /> Total Drainfield Footage,SU V.+Trench Depth Minimum _ Maximum • <br /> Curtain Drain Depth_ Signed:_ <br /> Effluent Pump: Pump Model PF3 Q )S . <br /> Pump cycle .----, <br /> times in minutes: on off Gallons per Cycle Company name:_ __Cr__,) ,..----/-7/1 L <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: <br /> (For Marion County Use Only) The above s em has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: ili Approved I I oved w'th corrections: see inspection report I I Denied <br /> Signed: 16V1h tle: ln _9_,1_ Date: 6 _ <br /> MC:S-41 rev:3/03;4/12;5/14;1 1/17 G:\Forms\Septic\S- s-Built2015Version2017.doc WHITE:Marion County; YE LOW: vner;PINK:Installer <br />