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r <br /> 4iiiiMwRION 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.SE 3- 2t i- O D 7 17 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 5130 B, -1 A✓' k•ifrri6 L o b fl <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ St2r 1' <br /> North <br /> - v:110 <br />\ ,, <br /> D,� Q(RoseA <br /> -P Ho <br /> , . is <br /> 9 �g0. G1n. <br /> ur_ \�v r �„� <br /> 0 ' �lrL� e <br /> w 1.111 :71'. <br /> 10w_ i Z <br /> c, PkQ� , , ` <br /> I <br /> \S° " c ; <br /> 6 C = 3 isle,1,1. - 7s , <br /> N°)` fit V p II <br /> � Pf 0f L l ti.e <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 HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow .50 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: / 0 a 6 total gallons [single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: R T' van I e1,cq..L S [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: C_OA/C.r t.- [ ] flow-through • 'I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: ► Header Pipe:/� '1 The system was installed by: <br /> Size/Mat'I � , _e V e- S d1 `i 8 Size/Mat'I / .1 O 3 I I Property Owner(permittee) <br /> _Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe Drop JN'Concrete DEQ License Number: .3 -7 cis 6 <br /> Pipe total depth i ( I Distribution I I Plastic DEQ R'�`y' Gs 7 2-�2_27 <br /> Certification Number: �lti. <br /> 'Drainfield Material(Alternative or perf.pipe) I N-c1 IT r c4-0 le- <br /> -.7 <br /> i CA/Lej <br /> Total Drainfield Footage3 76! Trench Depth Minimum,..N^Maximum � ICurtain Drain Depth Signed:_ 0-�1✓1/�/ <br /> Effluent Pump: Pump Model /� <br /> Pump cycle C <br /> times in minutes: on off Gallons per Cycle • Company name_T Qr r �, (C,(./1.S •'./If C, <br /> ATT Make and Model / (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 9,~(/ 7," y <br /> (For Marion County 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 [ I Approved with corrections: see inspection report [ ] Denied <br /> Signed: Title: Cat 1 (7 3 j _ Date: QI /ZL, <br /> MC:S-4I rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20l5Version2017.doc WHITE:Marion County; YELLOW.:Owner;PINK:Installer <br />