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COMMUNIW~MENT ...... <br /> ulL Na NS CTION D WS,ON <br />~,.~ SALEM, OREGON 97301.~ ~ ~ ~ <br /> <br /> ['"} ON-S[T..E SEWAG~YS~E,M INSTALLATION INSPECTION <br /> OWNER: ~;~ ~ ',/'/'~-~ ~',.,¢,'¢~-¢-'~ ? '_ SITE NO,__ q z/¢-- <br /> ADDRESS: ~" //.~,5/-~ ~/~ ~,j~..~ 3"~, ~ <br /> iNSTALLER: ~~ ~ PERMIT NO. <br /> SEPTIC TANK: <br /> . ~ DISPOSAL FIELD: . <br /> NO. GALLONS:_/~, ~ ~, ~ TOTAL LENGTH; <br /> MATERIAL: ~~;' ~/~ ~~ PIPE MAT'L: ~-~ ~'~ <br /> MANUFACTURER: ~/~ ~ TRENCH DEPTH: <br /> ROCK DEPTH: <br /> BUILDING SEWER MAT'S: ~ r/~ ¢~ . DIST. TO WELL: <br /> EFFLUENT SEWE~ MAT L: ~ ~ ¢~ ~, ¢~ f~ BOXES: .~~/ <br /> COMMENTS: ~ ~~a~' ~ ~~ ~~ <br /> <br /> In accordance with Oregon Revise~ ~tatUte 454.665; ~his certificate ~s issued as ~vid~nce of satisfactory <br /> comptetion of a subsudace or alt~ative sewage disposal system at the above location. <br /> INSPECTED B~ ~~ DATE: <br />MC 15.86 Rev 1~2 <br /> <br /> <br />