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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 /> SASALEM OR 97305 <br /> --,- 503-588-5147 • PERMIT NO. �3 —21- oo q 7 73— PRAT <br /> "//]ry <br /> T <br /> MARION J <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection -o e c / 0 6- <br /> SITE ADDRESS: ��°° 1�'0 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: °NA I"er 0 e <br /> Scale: 1"=S6 ' T <br /> S0 North <br /> 4,c___ 1 O 8 ��'° Toa. /6, <br /> a I o II <br /> Q ' Iw' G <br /> t <br /> It — ® hO <br /> t <br /> g _ p 0., i 2 I®, 17°.1,1 <br /> LI‘ . \ <br /> IN p <br /> t„ L7 Q , <br /> Co Vacca. Qo r&A <br /> le <br /> �°` . S�l o cfe Urall <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 y.ro Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I1 000 total gallons A.single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: `.O�i [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: ((per Ede-le— [ ] flow-through [ .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'I Size/Mat'l I 1 Property Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> 1 DRAINFIELD rock depth(inches) Box es <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: 7 .6 I 6 <br /> Pipe total depth 1 Distribution 1 Plastic 3� <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) ,"-' t <br /> 7 <br /> Total Drainfield Footage /.5d Trench Depth Minimum-4 Maximum <br /> Curtain Drain Depth_ Signed:_ I( <br /> Effluent Pump: Pump Model - _ <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ >(,'/ Ce,4/G-4.5 <br /> ATT Make and Model �] (py�lease print <br /> an additional sheet for components and materials not listed above. Date: / w/f�/I <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: Approved [ ] Approved with corrections: see inspection report [ ]Denied <br /> Signed: Title: �i Date: 7 3 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Bui1t2015Version2017.doc WHITE:Marion County; YELLOW.: w (,� <br /> ner;PINK:Installer <br />