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SITE ADDRESS: <br /> <br />INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> ~0~ ~; ~/~y ~-- /~-~- _/~~ OB ,; PERMIT NO. ~-- ~ 7 <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />scale: 1" = <br /> <br />I00' <br /> <br />North <br /> <br />(show all details and dimensions necessary to locate all components of the system in the future) <br /> <br />SYST~ MATERIALS ~ SPECIFICATIONS: <br /> <br />BOX(el): [ ] Distribution; [~ Drop / [~ Concrete; [ ] Plastic <br /> <br /> ,,,,., size: ,,,', , ,, <br />Tot.i Oraia~ield ,Dotage.' / ~)' , Rock Oe9~h.' Total:3O"; Under pipe: <br />T~"~eh Depth, ~inimum: ~&", ; Maximum, ~a"; ~rtain Drain Depth: <br /> <br /> ~ ~c~ ~: ~/~ , ~a~o.~ ~r ~o~: m/~ <br />Att~ ~ additional ~heet for c~---t~ ~ ~t~rialJ not liJte~ ~ove. <br /> <br /> INSTALL~i~S CERTIFICATION ~ <br /> I ~ER~BY 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 />ITY CO~94ISSION. <br /> <br /> I have tested the septic tank and certify <br /> it to be watertight. <br /> <br />system was installed by: <br /> Property Owner (permitee) <br />[ ] Li~ensed~e <br />Signed :'~ ~'7 / ~' %-- ~ · <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 /> ~] Approv~-.~ <br /> [ ] Appro~d ~Ah cor/%e~tion~: see inspection report <br /> <br />as-built.rrm 4/95 <br />MC-15-S41 <br /> <br />Title: ~ Date: II <br /> WHITE :Marion County; YELLOW:Owner; PINK: Installer <br /> <br /> <br />