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SITE ~DRESS: <br /> <br />INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> 1~7 ~ ~ ; PEP~MIT NO. ~- <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />scale: 1" = <br /> <br />North <br /> <br />(show all details and dimensions necessary to locate all components of the system in the future) <br /> <br /> SYSTEM MATERIALS ~ SPECIFICATIONS: <br /> <br />$.ptic Tank: Size: fO~ Met'l: ~(~, Mfg: <br /> <br />BOX(eS).' [~stribution; [ ] Drop / [~Concrete; [ ] Plastic <br /> <br />Dr&lnf~elcl Pipe: Size: ~'! ; Materiel: Header: ~/* ; Perf: <br />Total Drainfield Foot&ge:Zq~ ; Rock Dep~ Total: ~' ; Under pipe:/~" <br />Tr~ch Dep~, Minimum: Z~ ; Maximum: 36" ~ ~rtain Drain Depth: <br /> <br />· ffl.~t ~: ~mp Model: ~0 ~{ ; Static Head in System: ~ ft. <br /> ~mp ~cle Time: ~.~ ~ ; Gallo~s per ~cle: <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 ACCORDANCE WITH THE REQUIREMENTS OF <br />THE PERMIT AND THE RULES OF T~E ENVIRONMENTAL <br />QUALITY ~ISSION. <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 />[u~'~icensed Sewage Disposal Service <br /> <br />Company name: ' ~'~ ~..F- <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 ~e~TXsi~s <br /> [ ] Approved w p. ection report <br /> [ ] Denied ~ ./'7 ~ <br />Signed: ~ tT~.~"~' % ~' ~'~ Title:~ Date: ~ ~ ~ <br /> <br />as-built.frm 4/95 WHITE:Marion County; YELLOW:Owner; PINK:Installer <br />MC-15-S41 <br /> <br /> <br />