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• <br /> 1*.� MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> ..N. -� 5155 Silverton Rd NE (to be completed by system installer) <br /> - SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. 5SS-2 3 -0(5,56,2 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 5575 Fro'4 lekd Re!. Ai <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' T <br /> I. North <br /> APPROVED AS-BUILT <br /> DRAWING <br /> so p6 y.1-D\- <br /> ()-1 ).) <br /> (.5 P\ 1 i ' s <br /> .01 : <br /> & • <br /> Q �41 _♦/ E'A Sfi AL '.rl <br /> r f4o, Aoc,a 51 C\'‘`).4c1 <br /> i♦ <br /> (show all details and dimensions ne essary t. loc. e all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: � f(��t/L,Z �! <br /> Material: .E 1\1 [ ] flow-through )4 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: (( Header Pipe: The system was installed by: <br /> Size/Mat'l Size/Mat'l [ I Property Owner(permittee) <br /> �$[�[ Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe [ I Drop I I Concrete DEQ License Number: 3 -f 2 3 <br /> Pipe total depth I i Distribution I I Plastic T 3 y53 <br /> Z =�o�! DEQ Certification Number: <br /> Drainfield Material(Altemative or perf.pipe) <br /> r� <br /> Total Drainfield Footage,S2 5i Trenchen Depth Minimum )e"Maximuln3(y rt <br /> Curtain Drain Depth_ /(4i,4y ' Signed:_ ` i se" v_w u <br /> Effluent Pump: Pump Model ✓✓ . <br /> Pump cycle l' <br /> times in minutes: on_ off Gallons per Cycle Company name:_ grvl 1 CD 2e iyc.c 1.3 A t 0vt <br /> ATT Make and Model (p/lease print) <br /> Attach an additional sheet for components and materials not listed above. Date: T [•- /- 2 (/ <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 system is: rfi Approved [ ) proved with cor�r�e/ction�s� see inspection report [ I Denied n� <br /> Signed: I Qe Title 5j` W IDI'T U"`d- Date: ot`i' 91 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YE OW: caner;PINK:Installer <br />