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j'A\ MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> ' 5155 Silverton Rd NE ; (to be completed by system installer) <br /> • ; SALEM•OR 97305 . <br /> 503-588-5147 • 2 PERMIT NO. 9 ' Q Q .-5 Ock • <br /> MARION • • <br /> COUNTY h ://www.co.marion.or.us/PWB ection.uildin Ins <br /> g P SITE ADDRESS: 'LagI CO.St. 9-6 V.YE <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: - <br /> Scale:1"=100 ' .. .. 1 <br /> . - North <br /> • <br /> • <br /> • <br /> r r,-e1,1• ovLr - <br /> 9tom,• ', I <br /> • <br /> 0 <br /> • <br /> • RP�,a ••• It �` . r <br /> (show all details and dimensions necessary to locate all c ntponents of the system in the future) - <br /> SYSTEM MATERIALS AND SPECIFICATIONS: • INSTALLERS CERTIFICATION:• <br /> Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: \�5�®���p! total gallons ( ] single compartment . DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: rJ C *t '(74)dcuble compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: O.CIVNUf tk e, ( ] flow-through • . G I have tested the septic tank and certify it to be watertight. _: .• .1 <br /> • Effluent Sewer: 0Header Pipe:2u is The system was installed by: <br /> Size/Mat'I y .. . Size/Mat'l 0 • [ I Property Owner(permittee). • <br /> DRAINFIELD rock depth 1(inches) Box(es) <br /> JJ Licensed Sewage Disposal•Service• - <br /> Rock and under pipe •9 ( •i Drop ]Concrete DEQ License Number. �� . • <br /> Pipe- •� Sital depth .a, Distribution I I Plastic 1 3 • 1 S r <br /> II ::`DEQ Certification Number: <br /> Drainfield Material(Alternative of pelf.pipe) , erg- <br /> Total Dratnfleld Footage I . Trench Depth Minimum L )r, Maximum %J �I //�'/� <br /> . •Curtain Drain Depth_ .. . . . . ' •.. =. -. . - Signed:_ . �4 4l�tn gin.a.,- ... .. . . . .. <br /> v. <br /> Effluent Pump: Pump Model....).ND it 2- , <br /> Pump cycle _ . . <br /> • <br /> times in minutes: on off Gallons per Cycle Company names �,�:�.t, G <br /> ATT Make and Model • (please�rint) <br /> Attach an additional sheet for components and materials not listed above. . Date: . .s q./L-1 _ <br /> (FOr Marion County Use Only)*The above septic system has been inspected by Marion County. The in ormation has been determined to be accurate <br /> and the system is: [ ]Approved [ ]Approved with•corrections:see inspection report . [ ] Denied <br /> • <br /> • Signed: . Title: • ' Date: <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic4S-4l As-Buiit2015Version2017.doc WHITE:MdrionCounty;.YELLOW.•Owner;PINK-Instaile, <br />