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INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> ' (to be completed by system installer) <br /> <br />AS-~UILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />scale: 1" = ~O', ' % <br /> North <br /> <br />(show all details and dimensions necessary to locate all components of the system in the~future) <br /> <br />SYSTEM MATERI~tLS AND SPECIFICATIONS: <br /> <br />Se~)tlc Tank: Size: Mar'l: Mfg: <br /> <br /> D" qo <br />~fl~t S~or: Size: Mar'l: <br /> <br />Box(es): [ ] Distribution; ~ Drop / ~ Concrete; [ ] Plastic <br /> <br />Efflnent P%u~: Pump Model: (~T % O ; static Head in System: Iq ~_t. <br /> Pump Cycle Time: ; Gallons per Cycle: ~ <br />Attach an addltional sheet for co~m~onents and materials not listed ~ve. <br /> <br /> INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br />SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br />STRUCTED IN ACCORDA/~CE WITH THE REQUIREMENTS OF <br />THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br />QUALITY 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 Sewage Disposal Service <br /> <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 />t~.be accurate and the system is: <br />~ Approved ._~ <br />[ ] Approved ~wi~h corrections: see inspection report __ <br />[ ] Denied j / /Q ~ /9 ~ /~ ~ /~ ~/~ <br />S ig{ed: (<~~_/~~ Title:~'~'~-~'~ ~ Date: ~ '~ ~7 <br /> <br />as-built.frm 4 95 WHITE:Marion County; YELLOW:Owner; PINK:Installer <br />MC-15-S41 <br /> <br /> <br />