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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> -" ~ ' 5155 Silverton Rd NE (to be completed by system installer) <br /> —.►K:. SALEM OR 97305 g' � <br /> MARION 503-588-5147 PERMIT NO.. t,4i� -'` y 170OO 3 <br /> • <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection / 90 SITE ADDRESS: ` S v <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ ' <br /> North <br /> ie6 X1444 di el <br /> • <br /> • <br /> (show all details and dimensions necessary to locate all components of the system in the future) - <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- ' <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: de46 _ -total gallons p single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: LA) [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: fey ge [ ] flow-through itt 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 f/ OW ii Size/Mat'l ,14Property Owner(permittee) <br /> I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) ' <br /> Rock and, under pipe I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth • [ ]Distribution I I Plastic • <br /> DEQ Certification Number: <br /> Drainfield Material(Altemative or pert.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum . <br /> -Curtain Drain Depth Signed: • <br /> Effluent-Pump: Pump Model . <br /> Pump cycle J <br /> times innminutes: on off Gallons per Cycle <br /> Company name:_ ,� <br /> ATT Make and Model (please prin�t)�/ <br /> Attach an additional sheet for components and materials not listed above. Date: 4 �-- 027 • <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 is: [ Appr ed [ ] Approved with corrections: see inspection report [ ]Denied Signed? Title: EH'sl" 107,33 W Date: CJ p <br /> / <br /> MC:S-41 rev:3 3;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW:Owner;PINK-Installer <br />