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ON COUNTY BUILDING <br /> ��''`''1 555 CIOURT ST NE/PO BOS 14500 SPECTIOIN <br /> ,- ' SALEM OR 97309-5036 <br /> r- rion:1 INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> �„tCouP PA'- .. p (to be completed by system installer) <br /> ,SITE ADDRESS: i �-$f71' i,,�gg.„ Crt Lep ,c�� PERMIT NOc_c 5 —Z1I-0 2 2-9. _ <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> -:Seale: 1"= - ' E.- __ _ -- . • _. t ,. <br /> North <br /> .. <br /> • <br /> ,. . <br /> .. <br /> • . . <br /> . 1 . , <br /> . . <br /> . -- ... ) <br /> . . ----- , <br /> :. <br /> . . <br /> . . o.S. .® . try tl.) in . lilli <br /> • • ,e..-c,s <br /> 44. - 1 <br /> C. <br /> _ bav� �ikbt <br /> 00:: • J • / <br /> • <br /> 1 - -. ; ' s . <br /> / 1i <br /> • - (show details and dimensions necessary-to ocate-all components of the system in the fpture) . <br /> SYSTEM MATERIALS ANDSPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> �0 System Design Sewage Flow: (� Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> Septic Tank:Size:. X\St \ Y1 '1 Mfg: DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> v OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size: Mat'I Mfg: i I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer:Size: 2..4 Mat'l: 5 t Nb The system was installed by: . <br /> i I Property Owner(permitee) <br /> Box(es): ((Distribution; M..Drop I Joncrete; I l Plastic ,{stLicensed Sewage Disposal Service <br /> N 3 Drainfield Pipe:Size: /�/ ;Material:Header:}�� ;Pert: � DEQ License Number_ <br /> Total Drainfield Footage:'A!" ;Rock Depth:Total: ;Under Pipe: n <br /> Signed ,_..,_ ✓.---- <br /> Alternative Drainfield Materials: <br /> Trench Depth:Minimum: ;Maximum: ;Curtain Drain Depth: Company name: 4 ;LA.— .. Y 744 CS <br /> (please print) _ <br /> Effluent Pump:Pump Model: :Static Head in System Ft. <br /> Date: lY f3— ?mil <br /> Pump Cycle Time: ;Gallons per Cycle: ike4p1 1- Q m� %J Dw-2s <br /> Attach an additional sheet for components and materials not listed above. `t . Ham .e._it-S <br /> (For Marion County Use Only) - <br /> TO above septic system has been inspected by Marion County.The information has been determined to be accurate and the system is: <br /> [ Approved • <br /> [ I Approved with corrections:see inspection report - <br /> [I Denied. . <br /> Signed: Title: SI 10.,- ---51- 1 Date: )J1 /7 <br /> MC:S-41 WHITE:Marion County; YELLOW.Owner;PINK Installer <br /> rev: 8/00,6/01;3/03 <br />