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iiikiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NESA (to be completed by system installer) <br /> 5 3-88E O4 97305 PERMIT NO. 2.3— cog33-2„ <br /> MARION <br /> COUNTY htt //www.co.marionr /PW/Buildin Ins <br /> P' .o .us g pection <br /> SITE ADDRESS: Z3 CO 2 11 ,, <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= W T <br /> y North <br /> e ,,,ii- ,... ,,,N <br /> , 1/4., <br /> -c,_ ,.,, ,,,,,,s-,,,,A c.,)-- <br /> It \iik <br /> '\ <br /> Ci <br /> �'�, NJam' <br /> �� <br /> .7., S <br /> 1/2 p <br /> o <br /> 63_:____} > <br /> , [ '(---- <br /> Z.5r <br /> Ct --(COLI <br /> 1 — _....,,......____-------- <br /> �` 5 ,� <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 /> y DesignSewage7 ' Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 7(--,LX') total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: po <br /> ° [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: .,i c A-ye---, [ ] flow-through at 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 Size/Mat'l q g Set,,_ co-) I I Property Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) 6 <br /> Rock and under pipe gi I I Drop I I Concrete DEQ License Number: 39 3 I <br /> Pipe total depth 12_`' I I Distribution I I Plastic l 0 <br /> DEQ Certification Number: <br /> • Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage/t CI)�Trench Depth Minimum Maximum <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model )PE;()U5--- <br /> Pump cycle ,t-times in minutes: on off Gallons per Cycle Company name: Q ^-II—c.A <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date:____4W a <br /> (For Marion County Use Only) The above sep system has been inspected by Marion County. The information as been det ined o be a curate <br /> and the system is: [Approved I ] pproves with corrections: see inspection report I ] Denied 12 ,. <br /> Signed: _ ill T.--: Iy s 1�I 0 Date: TT i"--. <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms eptic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELL W:Oivn r;PINK:Installer <br />