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mk:-� ` 'MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM O 97305 <br /> 503-588-5147PERMIT NO.5S5-9..li—•00334L\ <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 4.126\ �1/\‘.,721— 5;-- WL <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1 = T <br /> North <br /> A— c. 10.1' <br /> 13— L 1O <br /> A — L i t-0 . <br /> AK —F ILn- t r 6 H <br /> Pt - C 1SS' <br /> A _ I-1 l(03` IF sr --AIo ►q to' <br /> — L I '3 <br /> S —D IC` <br /> -3 — • I ' we11 <br /> VS— F ITr 60.,09, <br /> 3-6 13\-1; 1 A 3 <br /> E - 1-1 I 7 -E-,(;5.V;v,..) <br /> Rio'Jst. <br /> (show all details and dimens ons necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS1 AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> �dY� Gallons/DayI HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- • <br /> TANK Size: ISM total gallons IA.single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ` , \ - [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: WD\`t't(_ <br /> Material: (;)I\(_r-L.L [ ] 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'I 5L in(-1l1 PVL Size/Mat'l 3 s64-to PvC I I Property Owner(permittee) <br /> VINLicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es)Rock and under pipe & >4,Drop I I Concrete DEQ License Number: S(o 23c <br /> Pipe total depth [T. I I Distribution I I Plastic Q R 7,S <br /> 1 r DE Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) 3 5__\CIO ?ex-Q. <br /> Total Drainfield Footage L\'v Trench Depth Minimum 2(--I" Maximum35' <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ 1J^ A)rik,r� <br /> ATT Make and Model (plea�s]e print) <br /> Attach an additional sheet for components and materials not listed above. Date: 8 - 1�- LA <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: ft4 Approved [ I Approved withc corrections: see inspection report [ ] Denied <br /> Signed Title: li`4—J 1 102Z3 4'15- Date:e/ /� <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County: YELLOW:Owner;PINK:lnstaller <br />