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INDIVIDUAL <br /> <br />ON-SITE <br /> <br />SITE ADDRESS: <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br /> scale: 1" = ' <br /> <br />SEWAGE <br /> <br />(to be completed by system installer) <br /> <br />SYSTEM RECORD <br /> <br />(show all details and dimensions necessary to locate all components of the system in the future) <br /> <br /> INBTALLEP~ C~TIFICATI~ <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br />SYSTEM INST~T.?.Rn AT THE ABOVE ADDRESS WAS ~CON- <br />STRUCu'w.U IN ACCORDANCE WITH THE REQUIP~4ENTS OF <br />THE PERMIT AND THE RD'LES OF THE ENVIRONMENTAL <br />QUALITY CO~4ISSION. <br />[ ] I have tested the septic t;b~k and certify <br /> it to be watertight. <br /> <br />The system was installed by: <br /> <br />(please print) <br /> <br /> ~YST~ MATEPJ~%L~ ~ SP~IPICATI~ ~ <br /> <br />D~s~ Tanks Size:~ ~ ~t'l: Mfg: <br /> I ~11 <br /> <br />~(.,)~ [ ] Distri~tion; ~ Drop~/ ( ] Concrete; [ ] P}astic <br /> <br /> ; ~t~: Header , rf <br /> <br />~ ~ Mint~m. t~m, ~r=ain Drain ~pth: <br />· f~l~ ~ ~ Model: ~ ; S~a=ic Head tn System: <br /> ~ ~cle Time; ; Gallons Der <br /> <br /> (for Marion County use only) <br /> The above septic system has been inspected by Marion County. The informatipn has been determined <br /> to be accurate and the system is: <br /> [~] Approved <br /> Approved with ~orrections: see inspection report <br /> [ ] Deni~ _ /t~ <br /> <br />as-buil~.frm 4/~ o WHITE:MArion C6unty; YELLOW:Owner; PINK:Installer <br />MC-15-S41 <br /> <br /> <br />