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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 /> SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. 2 3 --00O /S9' <br /> MARION <br /> COUNTY htt //www.co.marion.or.us/PW/Buildin Ins ection <br /> P� g p SITE ADDRESS: /96:v90 &('/y i N 5G <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ ' T <br /> North <br /> 3 e6 1)461-e/ <br /> �'g() <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 /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow Gallons/Day STALLED 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 /> Manufacturer: <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] 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 Size/Mat'l ➢Q'Property Owner(permittee) <br /> [ ] Licensed Sewage Disposal Service <br /> DRAINFIELD rock deptt4(inches) Box(es) <br /> Rock and under pipe 9 [ I Drop [ I Concrete DEQ License Number: <br /> Pipe total depth .Zy —. .1111 I I Distribution [ I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage <br /> g eig0 Trench Depth Minimum' Y Maximum _1'0 <br /> Curtain Drain Depth Signed: • <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: 4Oi'8l4/ /l/lL uCe! <br /> ATT Make and Model (please pMnt) <br /> Attach an additional sheet for components and materials not listed above. Date: Vi.,0 sip' <br /> (For Marion Count se Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [/]'Approved J I Approved with corrections: see inspection report [ J Denied <br /> Signed: Title: H —5i IO1)5535 Date:_/30/ _ <br /> MC:S-4I v:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-BuiIt2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />