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1 <br /> amMA:RION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5i55 Silverton Rd NE SALEM OR 97305 (to be completed by system installer) <br /> 5l}3-588-5147 PERMIT NO. 5'- - —CO 6c 94{ <br /> MARION <br /> COUNTY http://www.eo.marion.or.usIPWBuildiaglnspection <br /> SITE ADDRESS: j60� cS 'L->-"t Y <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: j(CLleneslii& I 012. Q"7 <br /> Scale:1" 0 r a I T <br /> North <br /> 4`w <br /> op [yes` <br /> 41, 73e <br /> r A <br /> N"Ns,NN,,,,,,,N? <br /> 44 Or <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 /> 1 i �� /4'(-'� I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System DesignS e.,Ftow 'rig— 'Gallons/Day k�Gal <br /> ewaSw STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK 3 4 total gallons [le single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> (pee, OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer 14041 V ( ] double compartment <br /> Material: se z_Vi ( J flow-through QQ I have tested the septic tank and certify it to be watertight <br /> Effluent Sewer: t rr Header Pipe: �1,,r� `The system was installed by: <br /> SiSize/Martf`K /fU�'. Size/Marl ` `R ( J Property Owner(permittee) <br /> DI Licensed Sewage Disposal Service <br /> DRAINFIELD s - rock depth(inches) Box(es) <br /> Rock and ' under pipe r;x ( 1 Drop f7(kii Concrete DEQ License Number: "'glee <br /> Pipe i total depth [M Distribution [ I Plastic DEQ Certification Number. kr.io i <br /> Drainfield Material(Alteemative or perf,pipe) <br /> 1 <br /> Total Drainfield Footage - Trench Depth Minimum Maximum <br /> Curtain Drain Depth i — Signed: <br /> Effluent Pump: Pump Model . <br /> Pump cycle ; ' i _ <br /> times in minutes: on off —'" Gallons per Cycle Company name: ai-/er net $,tin vF- t.-1 L L-( <br /> J <br /> ATT Make aid Model r --.... (please print) <br /> Attach an additional skeet for components and materials not listed above. Date: _.— <br /> jFor Marion Coun AJse Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the'system is: [4, Appro [ 1 Approv d with corrections:see inspection report [ [Denied <br /> Signed' Title: \N€1. ICS-3 Date: ais/Z''1 <br /> MC:S-41 rev:3/03;4/12 5/14;11/17 G`CForms'Septic4S-41 As-Built20.15Version20l7.doc WIIITE:Marion County:YELLOW:Owner;PINK.:Installer <br /> z <br />