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• <br /> ills ]SYSTEM RECO oR„... <br /> INDIVIDUAL ON SITE SEWAGE . <br /> (to be completed by system installer)SITE ADDRESS: 215 .J 5191U aaYl'ildiij <br /> �/ '� ; PERMIT NO. `Q <br /> 7 01405 I <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: __ __ _ • <br /> • <br /> scale: 1" _ t <br /> ?Owe, /'�AWN No th <br /> N 0 E4I,be,a- 4ui(.S "fiw°° <br /> x Ell , . <br /> . . <br /> .ig <br /> Z#6,•E" <br /> • <br /> VJ <br /> . rrAlg -lila it . <br /> x MARION COUNTY <br /> X BUILDING INSPECTION <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> r <br /> • <br /> SYSTEM MATERIALS AND SP=CIlSGTZm18: 1 EBB kl.LZHS CERTIFICATION: • <br /> `////������ I.. I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br /> Septic Tanks Size: Mat'1: C f 1'1tf Mfg: 1�11 S SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br /> STRUCTED =ACCORDANCE WITH TEE REQUIRBMENTS:CF <br /> Dosing Tanks Size: t4i2A Mat'1: ME4: THE PERMIT AND THE RULES OF TEE ENVIRONMENTAL ' • <br /> is •L1 ITY COMMISSION. <br /> Effluent Sewers Size: Ql Mat'1: $� C •. I have tested the septic tank and certify <br /> it to be watertight. <br /> Box ). [ ] Dist tiOn; [ I Dr / [ ] Concrete, [ ] Plant <br /> The system was installed by: <br /> eld Pipe: Size: , Ma al: Header: ; Pert: [ ] Property Owner (permitee) <br /> Total Dr afield Too tq Licensed Sewage Disposal Service <br /> • Cage ; Rock the Total: er pipe: <br /> M,i Trench Dap 1 Minimum: ; Maximum: ; Curtain Drain the Signed: <br /> Effluent pump Pump Model: ; seats Head is System: ft. Company name: 1 Sevv,ce <br /> (please print) <br /> • Cycle Time: ; ions per Cycle: <br /> Attach en additional sheet for components and materials not limited above. Date: ` <br /> (for Marion County use only) <br /> The above septic system has been inspected' by Marion County. The information has been determined <br /> to be accurate and the system is: <br /> [ ] Approved <br /> [ ] Approved with corrections: see inspection report <br /> [ ] Denied <br /> Signed: Title: Date:_' _ <br /> as-buirt.frm 4J95 ' WHITE:Marion County; YELLOW:Owner; PINK:Installer <br /> MC-15-S41 <br />