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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> gliki <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> � <br /> 503-588-5147 PERMIT NO. —t:.�C)1 g 9 7 <br /> MARION COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: _ i-- ,i /44-'\07' <br /> 'AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= PrOeZ1-4-u) i Y.t - , <br /> r — — — — — — — — — — — — — __r orth <br /> 4 <br /> e S P► -C.=ZLJI <br /> �j lit` w . R. -D �3S <br /> ri '2.`` ` c. <br /> �I �` ® <br /> I ;:;.� Q Tot <br /> / . <br />. ow-.. <br /> I A ' <br /> Nevem <br /> , 46CA-ce <br /> (show all de ails and dimensions necessary to ocate all components 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: �- total gallons [ ] single compartment' DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> / double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: t,./C,t,4, <br /> Material: /" C' [ ] flow-through have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: v Header Pipe: The system was installed by: <br /> Size/Mat'I �� pv'/.- Size/Mat'l Alpr D0Property Owner(permittee) • <br /> I Licensed Sewage Disposal Service <br /> DRAINFIELD rock dep (inches) Box(es) 3��� <br /> Rock and under pipe I I Drop ncrete DEQ License Number: <br /> Pipe total depth / 7,../ I I Distri u6 lion Plastic <br /> DEQ Certificatio umber: D <br /> Drainfield Material(Alternative or perf.pipe) Seem Total Drainfield Footage,�t/z Trench Depth Minim jr Maximum3 O <br /> Curtain Drain Depth_ s. Signed: <br /> Effluent Pump: Pump Model rP 3L/4/� _ <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: S kbre---41-IL <br /> (please print) <br /> ATT Make and Model " / <br /> Attach an additional sheet for components nd m erials not listed above. Date: <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: I-] Approved I I Approved with corrections: see inspection report I ] Denied • <br /> Signed:7, i�Title: F H5 Date: WaVig L 1 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Bui1t2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />