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SITE ADDRESS: <br /> <br />INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> ~ ~.. /~ J_~ 6~/ ~ ~ ; PERMIT NO._~--~ <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br /> = ; <br />scale: 1" = ~O <br /> <br />North <br /> <br />(show all details and dimensions necessary to locate all components of the system in the future) <br /> <br /> SYSTEM MATERI~__~SANDSPECIFICATIONS~ ~ * <br />$.ptic Tank= Size:~ Mat' 1:~ Mfg:~~l '' <br />~sing T~ Size: Met'l: Mfg: <br /> <br />· fflu~t S~r= Size: Met'l: <br /> <br />~(es): [~istribution; [ ] Drop / [ ) Concrete; [~lastic <br /> <br />D~ainf~14 Pipe: Size:~; htertal: ~ . <br />Total Drainfield F~tage:~; Rock Dep~: Total:~ Under pipe: ~_ <br /> <br />Ir~eh ~p~ ~inimum: ; ~aximum: ; ~r~ain Drain Depth: <br />Ifflu~t ~: ~mp Model: ; Static Head in System: fi. <br /> <br /> ~mp ~cle Time: _ ; Gallons per ~cle: , l <br />At=a~ ~ additional sheet for c~onentl ~d ~terta~l not ltltld ~ove. <br /> <br /> INSTALLERS CERTIFICATION: <br /> I REREB¥ CERTIFY THAT THE ON-SITE SEWAGE <br />SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br />STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br />THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br />1¥1'~ COMMISSION. <br /> I have tested the septic tank and certify <br /> it to be watertight. <br /> <br />The system was installed by: <br />]Property Owner (permitee) <br /> Licensed~wage D~ <br />Signed:f/ <br /> <br />Company name: <br />(please print) <br /> <br /> (for Marion County use only) <br />The above septic system has been inspected by Marion County. The information has been determined <br />to be accurate and the system is: <br />[ ] Approved <br />[ ] Approved with corrections: see inspection report <br />[ ] Denied <br /> <br />Signed: <br /> <br />Title: Date: <br /> WHITE:Marion County; YELLOW:Owner; PINK: Installer <br /> <br />as-built.frm <br />MC-15-S41 <br /> <br /> <br />