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abiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMITNO..555 - 3 'vt7 n% -?gMT- <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 1 10 aGk ey L.1,1 . Per la I O t� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: _ <br /> Scale: 1"=,2O' T <br /> (Jro�oS R� North <br /> Srg <br /> I . <br /> 0 � ' l�l-4 <br /> et• <br /> el, • "ae46-----)r-r-ir ‘5,4 N <br /> 10' _�' 1 <br /> �., erg'-0. <br /> '(` .3 <br /> ��� y 13 <br /> 35 <br /> io <br /> /L <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 375 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: )000 total gallons [ single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> IA/AYE [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION.- <br /> Manufacturer <br /> Material: GOf)G.(Z'11' [ ] flow-through I [ I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: r, Header Pipe: !I The system was installed by: <br /> Size/Mat'I / /V 303"/nt- Size/Mat'l i.FJ-303y,L I I P9.perty Owner(permittee) • <br /> It.reicensed Sewage Disposal Service <br />. DRAINFIELD rock depth(inches) Box(es) ,�/ <br /> Rock Vial <br /> pipe I op I oncrete DEQ License Number: <br /> ...Ai otal depth _ I I Distribution I I Plastic �— <br /> DEQ Certification Number g e <br /> Drainfield Material(Alternative or perf.pipe)EZ c1OMI o?f"Tern) PEAL <br /> ,' l ' <br /> Total Drainfield Footage �D/ Trench Depth Minimum 7D Maeimum_7 / <br /> Curtain Drain Depth Signed: "?Z''----2' <br /> Effluent Pump: Pump Model . <br /> Pump cycle / <br /> times in minutes: on off Gallons per Cycle Company name:_pGtC•'cr G I IQ k-x(A k4a)i1� 2-GG <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: a"6 / C ?L/ <br /> (For Marion Count#Jse Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [vi Approved [ I Approved with corrections: see inspection report [ ] Denied <br /> Signed: Title: '11-1.‘"'S1 k I. -3---S9••"P Date: gf/S. <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015 Version2017.doc WHITE:Marion County: YELLOW:Owner;PINK:Installer <br />