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iiihrMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. 5--zy-00Git-ictg <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection [6S- jd -� . S <br /> SITE ADDRESS: <br /> 'AS-BUILT PLAN OF CONSTRUCTED SYSTEM: `lCCItt- CAL <br /> Scale: 1"_ Ot <br /> kNO t t <br /> IOt S21 lit Tot 0North <br /> �L IV <br /> I t'l <br /> 30' <br /> nl <br /> E5Vt 5 re It's 5` <br /> 1 <br /> 1SDO ' <br /> . POSe.e/riot <br /> (show all details and dimensions essary tolate'alll c co nt nponents'oTthL�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_37 5 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: j5v total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: (,)o,,t-{ <br /> /� double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> [ ] flow-through , I have tested the septic tank and certify it to be watertight. <br /> Material: vir,r,eWit, <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'I 1 .Z.S'' &4/1 1 CD Size/Mat'I I I Property Owner(permittee) <br /> J4Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) C, <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: 13 61 <br /> Pipe total depth L3KI Distribution I I Plastic <br /> DEQ Certification Number: --L35 L(Q <br /> Drainfield Material(Alternative overt'.pipe) 12 fIc x.i • <br /> Total Drainfield Footage Trench Depth Minimumte Maximum9Z' <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model PF Q S • / <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: �(�� C <br /> ATT Make and Model , (please print) <br /> Attach an additional shee>cleats_ <br /> and materials not listed above. Date: 84L15/7 y <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: 0/Approved I I Approved with corrections:o see inspection report [ ] Denied �,J <br /> Signed: % % /11' ` Title: (1J Date: Zr ��� J <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 />