Laserfiche WebLink
MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> dibi <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> `` <br /> 503-588-5147 PERMIT NO. 555 21/`"OO /zS1 ' PRHr <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: I 1 S' H.,Plc Si. <br /> 6R1r , O 11 973yo <br /> 'AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' T <br /> North <br /> • <br /> KI <br /> • <br /> ?1,Ltel .5 I f-/ 6JSc <br /> 'fl 14 in; .4 ►, <br /> H V.1l,los,- pL;Sl.c <br /> S 're 1IL PVL <br /> --TA.1 IC .Lw 5cv+1c IvDQ3 ,rd . <br /> ` 9 I dNV M� I <br /> v�a;�Y. may, <br /> ra <br /> . <br /> r IN 18 <br /> • <br /> 1 A,P 2-C. T, (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_ 3 06 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I 6 00 total gallons 1;04 single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: Tyt��•�•ivwto p[ ] <br /> Material: pi A S I.t [ ] flow-through <I 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 4" pve_. Size/Mat'l 11 Property Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) _ 2 <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: 3 -1 a 3 1 <br /> Pipe total depth I I Distribution I I Plastic 3 3DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum_ .. / <br /> Curtain Drain Depth !� Signed:_ 1 L^ L 6-�( <br /> Effluent Pump: Pump Model <br /> Pump cycle ^ <br /> times in minutes: on off Gallons per Cycle Company name: k (K ) ©t Zc E `Z a V aik. Oyt <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: e e 7 6 _" <br /> (For Marion Count Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system i : Approved I I Approved with corrections: see inspection report ( ] Denied <br /> �Z ��/ I <br /> Date: <br /> Signed: ,� Title: <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:Installer <br />