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SITE ADDRESS: <br /> <br />INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> //m <br /> lib ~/ ~-/11~ ~ , ~RMIT NO.' ~ <br /> <br />AS-BUILT PL.%-N OF COHSTRUCTED SYSTEM: <br /> <br />(show all details and dimensions necessary to locate all components of the system in the future) <br /> <br />MATERI2t~S LIST FOR SYSTEM: <br /> <br />septle Tank: Size~ <br /> Material: <br /> Manufacturer:,~%,% <br />Effluent Sewer: Size: <br /> Material: <br /> <br />~ea~er ~p~: Size: <br /> <br />Distribution Pipe:Size: Material <br /> <br /> INstALlERS CERTIFICATION: <br /> I M~REBY CERTIFY THAT THE ON-SITE SEWAGE <br />SYSTEM INSTALLED AT THE A~OVE ADDRESS WAS CON- <br />STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br />THE PERMIT A~D THE RULES OF THE ENVIRONMENTAL <br />QUALITY COMM~SS~ON, <br />[ ] ~ have tested the septic tank end certify <br /> it to be w~tertight-~ <br /> <br />(for Marion County use only) <br /> <br />The above sept'lc system has been inspected by Marion County. The information has been determined <br />to be accurate and ~he system is: <br />[~] Approved ~ <br />[ ] Approved(.wi~h,z~orrect~: se~ inspection <br /> <br />~s-~uilt.frm 3/95 <br /> <br /> <br />