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glitiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SY5TEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. <br /> MARION /3� L G J <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection <br /> SITE ADDRESS: <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' 4111 <br /> A-- • North <br /> AEJ l <br /> © � CZ,\ Cie— <br /> . <br /> s7 . )51 <br /> l <br /> ,� 0 <br /> iv. <br /> ,OS <br /> t.7.z <br /> (show.11 details and dimensions necessary to locate 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: t d lJ O._ total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> W(. .t cC [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> , Manufacturer. <br /> Material: -"'a) • [ ] flow-through ( rave tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: I t Header Pipe: d_j 1 r ` / /The system was installed by: <br /> Size/Man ����' Size/Mat'I w ���/// .(' roperty Owner(permittee) <br /> [ ]Licensed Sewage Disposal Service <br /> DRAINFIELD , rock depth(inches) Box(es) <br /> Rock and under pipe O 4N I I Drop oterrAncrete DEQ License Number: <br /> Pipe total depth 56` istribution I I Plastic �'� a <br /> DEQ Certificate Number: <br /> Drainfield Material(Alternative or pelf.pipe) A <br /> Total Drainfield Footage I 1� �nit Trench Depth Minimu D Maximum <br /> Curtain Drain Depth_ Signed: <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> J <br /> times in minutes: on off Gallons per Cycle Company name: t <br /> ATT Make and Model / (please(ple prir t)y ' <br /> Attach an additional sheet for components and materials not listed above. Date: '/---,'l�1 <br /> (For Marion Coun 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: [Approved [ j Approved with'corrections:see inspection report [ ]Denied <br /> Signed: � Title: . T1 ST 16ZT . Date: —(� <br /> (/1 2,/7J0 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-BuiIt2015Version2017.doc WHITE:Marion County;YELLOWOwner;PINK•Installer <br />