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MARION COUNTY BUILDING INSPECTION <br /> Oil <br /> + INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> MARION <br /> TY 503-588-5147 PERMIT NO. �- 610 2 2-3 <br /> http://www.co.marion.or.us/PWBuildinglnspection SITE ADDRESS:3 5 4 3 /c 14A/413 !/71- 5 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: I-Yd v S E`` 9� �5' <br /> Scale:1"_ _ . _ __ ,_ <br /> North <br /> • <br /> • <br /> • <br /> 567aa /a-77A e-/-7.&`tb <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 /> System Design Sewage Flow Gallons/DayI HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> Y g STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANKSize: total gallons [ ] single compar ent DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> [ ] do •e c• •partment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: lir 11 rough [ I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: e .er Pi•e: 4 The system was installed by: <br /> Size/Mat'I i l/ • '1 lb Property Owner(permittee) <br /> �� Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(i ghes)1 rill <br /> Rock and under pipe u ) [ ]Drop I I Concrete DEQ License Number: <br /> Pipe to 4.-• . I Distribution Plastic <br /> DE ' n N ber: <br /> Drainfield Materia •ltern or p= ..pe) 7 <br /> Total Drainfleld ,`•.•ge Trench Depth Minimum_ Maximum_ <br /> Curtain Drain D.j.S' Signed: 4/( - <br /> - <br /> i Effluent Pump: • •p :del . <br /> Pump cycle <br /> times in minutes: •n off Gallons per Cycle Company name: <br /> (please print) <br /> ATE Make and Model /j •-� <br /> Attach an additional sheet for components and materials not listed above. Date: v 7 — G- ' _© Z V __._,„ <br /> (For Marion Coun Ilse 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 4 <br /> Signed: Title: ` i01.75- 3t) Date: a/Z5 C <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:1Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW:Owner;P'NK•Installer <br />