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iiimMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. 555 — 2 V— 00 G 7O - PR r-i f <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: ] Z 09 I N<p p y, (A)47 5i, J e, ers6y <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ T <br /> North <br /> L: 2 cc' K 1. <br /> - -�'� 2 1 <br /> g.c. :I s,' / r <br /> 3o <br /> A-E <br /> 1 <br /> • <br /> - • t ) . P g. <br /> X• + <br /> 35t I o <br /> f3-6 _ III' P g'�'Pb��a <br /> 3"t le: f • <br /> v, w — I dd <br /> ..1 ^ to <br /> 0I _ Q g 1/'. <br /> �i III . '11 <br /> 1n n <br /> :, <br /> * d <br /> 5 <br /> Kk <br /> 1 <br /> . <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 /> u I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow 1T 3O Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 156 0 total gallons Ni single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: ='a C.I •.��� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: ']as 4.4_ [ ] flow-through 1 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: t, Header Pipe: �� The system was installed by: <br /> Size/Mat'I 9 P1L. Size/Mat'l Y P4Z- I I Property Owner(permittee) • <br /> KLicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe X Drop XConcrete DEQ License Number: S G 2 3 <br /> Pipe total depth I I Distribution I I Plastic DEQ Certification Number: )- 3 ys 3 <br /> Drainfield Material(Alternative or perf.pipe) f Z r/o w <br /> Total Drainfield Footage YSb Trench Depth Minimum2Y Maximum 2 B _ <br /> G/ <br /> Curtain Drain Depth_ y8' Signed:_ 12 - L G,.__,(4 - <br /> Effluent Pump: Pump Model 10A . '/ <br /> Pump cycle �/ (- <br /> times in minutes: on off/ Gallons per Cycle _ Company name:_ r\r r. / Oo Zt L'XCq.'..1- .e... <br /> ATT Make and Model N/A (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 9 - 2 c —2 y <br /> (For Marion Count 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 [ I Approved with correct'ons: see inspection report [ ] Denied <br /> • <br /> Signed: f� Title: g 5 Date: d )� <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE.:Marion County; YELLOW:Owner;PINK:Installer <br />