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• MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> Mii <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. Z.;1—60 S 77.3 -n�/t7 T <br /> MARION <br /> ' COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: I,� (r'/Z L,Gty L/y S6 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 7C ow <br /> ..., <br /> Scale: 1"= 190 T <br /> I fV-U I)j k, 4)..1i z cgo North <br /> 0- 3 61 °� evitli),55 <br /> — c--- 2o' <br /> Conner <br /> C U ., I`ItL__p 4 l dI e oo,' fa tl o -h. 5`73' <br /> fea, ,-- s et,f1,L`6o, <br /> ,Ar;e_I _ el+ij <br /> Q I&Cal- <br /> 1 <br /> LW 'T-- ___. <br /> 1 ___, <br /> c,,,,,,c.....,,,,, #,....„./ <br /> ..,, . <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 /> System Design Sewage Flow GiS 0 <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM Gallons/Day IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1 t roo total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> double compartment <br /> Manufacturer: ki.e,(40 <br /> [p] OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: (e - 6' [ 1 flow-through [)4_1 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 i"I is fa, 4Irr ZQo chs/-C 4Size/Mat'I [ I Property Owner(permittee) <br /> [,Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es)Rock and under pipe - I I Drop I I Concrete DEQ License Number: 3 61 ti p <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: t 7..r <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum / <br /> Curtain Drain Depth Signed:_ � C . 13 eij -( <br /> Effluent Pump: Pump Model . <br /> Pump cycle r � <br /> times innminutes: 1eC.1ei on off Gallons per Cycle Company name:_ 6��CA `f'tb_ir <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date:11/17/7 3 <br /> (For Marion Count se 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 I Approved with corrections: see inspection report I I Denied <br /> Signed: Title: - .-S T 1013 l ' Date: V7_;7 4 <br /> MC:S-41 rev:3/ ;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built201 5Version2017.doc WIIITE:Marion County; YELLOW:Owner;PINK:Installer <br />