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601 MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer)503-588-5147 PERMIT NO. 555- c09,3 3 - <br /> 65 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: JC0)aZ Gln4r12120(2,9 Rd 7\.(� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=.50, T <br /> - North <br /> N £ <br /> S r wee <br /> A-13- )f )56r+ <br /> dq - c am al, ' .. <br /> A -p. 17� ae s <br /> f3 'P= (v ' e <br /> ��'" £,5� — <br /> � c <br /> ,I <br /> _ r <br /> —I!,. . - <br /> . )7f& ed "` <br /> )og' \Q- <br /> . L . <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MAT'7 E Jr ERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage FlowGallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: ).5 GD total gallons ,I ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: ,�{ <br /> Wok C3nere 1� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: CO n Cr L re-re [ ] flow-through I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: � ii Header Pipe:,j ii The system was installed by: <br /> 97 d4 Size/Mat'I .B.5 Size/Mat'l 7 -3 V rvC I I Property Owner(permittee) <br /> (a Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe (&' #Drop "(Concrete DEQ License Number: t?PS�� <br /> Pipe total depth )o� I I Distribution I I Plastic /// �/ <br /> �+ �n DEQ Certification Number: ie qy� <br /> Drainfield Material(Alternative or perf.Ripe) 'E.I F 'PP. <br /> E' <br /> Total Drainfield Footage //co ' <br /> Trench Depth Minimum RV Maximum.36 <br /> Curtain Drain Depth Signed: -'1,/ <br /> Effluent Pump: Pump Model . <br /> Pump cycle c <br /> times in minutes: on off Gallons per Cycle Company name:_� C-jr- CJ A i �/max G U.,,c_. <br /> ATI'Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: �/ 747y <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 [ ] Approved with corrections: see inspection report [ I Denied <br /> nq/ .f� <br /> Signed: Title: (43r ]Q�?�?��- f�` Date: ` 12 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20l5Version20l7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />