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:IIARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD: <br /> jp,,.5155 Stiverton Rd NE (to be completed by system>installer) - ' - <br /> •,SALEM OR•-97305 L <br /> ARION 503-588 5141 • PERMIT NO. 2; 'OcI 6 9 2. <br /> COUNTY ) http://www.co.marion.or.us/PWBuildinIns ection •" /- ,,tt t <br /> g P: SITE ADDRESS:') 112 ' <br /> : <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM:- • <br /> Scale:1":=26' `¢ I <br /> l . " North <br /> iu...-----7\----..,,,,,\ <br /> 6. (( 0 ca <br /> Li <br /> 1 <br /> 1- <br /> : V . ' <br /> a <br /> } \ . <br /> ` Jy <br /> _ ._..---u-';,-..,2_,...ii-i!:,.1,..-----4.-!,.• , <br /> (show all details and dimensions ecessatyto ()Cate all co ponents o e system in the fu e) <br /> SYSTEM MATERIALS AND.SPECIFICATIONS:- INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow '�S ��Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THEABOVE ADDRESS WAS CONSTRUCTED IN ACCOR= <br /> TANK Size: k•i , total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES. <br /> Manufacturer: tAC(i\'c' 1 "c're le [ ] double compartment OF THE ENVIRONMENTAL;QUALITY COMMISSION_ <br /> Material: ( xJ:t $e— [ ] flow-through 14.1 have tested the septic tank a fy' o•b atemght _ ,,,,j <br /> Effluent Sewer: Header.Pipe: �: The system was installed by: <br /> r;; .: Size/Mat'l IA tt 5t 6 'eV( Size/Mat'l "-1 '7 Z + Mr(` 1I Property Owner(permittee) ` <br /> I 1 Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) 1 Boxes) <br /> _ Rock and under pipe (I l [XI Drop 11+1-Concrete DEQ License Numfier: :: <br /> Pipe L t t . <br /> _ . total depth i I I Distribution ) )Plastic <br /> DEQ Certification Number: • <br /> . <br /> Drainfield Material(Alternative or pert.pipe) (2,7 241 VGT <br /> Total Drainfield Footage 90€0 Trench Depth Minimum 2'I Maximum2I <br /> Curtain Drain Depth_ Ai A Signed: PATA\ i I <br /> Effluent Pump:V Pump Model /116C <br /> Pump cycle <br /> times in minutes: on off ' Gallons per Cycle Company name: ` <br /> n (please print) .; <br /> NIT Make and Model MIA [ ;� <br /> Attach an-additional sheet for components and materials not listed above. . - Date: g_ k 5—' L` "i <br /> ' (For Marion County se Only) The above septic system has been-inspected by Marion County:The information;has been determined to be accurate i <br /> and the system is: [proved [ ]Approved with corrections:see inspection report _ [ I Denied <br /> i <br /> Signed: Title: [�Z2J7 - Date: 4•rn/.2l-1 _ <br /> MC S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc ` 'WHITE.Marion County;YELLOW PINK:Installer ', <br />