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SITE ADDRESS: <br /> <br />INDIVIDUAL ON-~StT. E SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />scale: 1" = ~.~/'_ <br /> <br />North <br /> <br />tl~ <br /> <br />O0 <br /> <br />(show all details and dimensions necessary to locate all components of the system'~kn the fu ute) <br /> <br /> SYSTEM MATERIALS A~D SPECIFICATIONS: <br /> <br />D~s~ T~{ Size: ~t'l: Mfg: .... <br /> <br />~a~fleld Pt~ Size: ; ~tertal: Heade~:~ Perf: <br /> <br />To~l Drm{nf~eld F~ta~e, ; P~ck Dep~, Total:, ; Under pipe <br />~ De;~I Mini~m: ~ ; ~xi~m: ~ ; ~rgain Drain ~pth:~ <br />~EfX~t ~ ~mp ~del: ; Static Head in System: <br /> <br /> ~ ~cle Time: ; Gallons per <br /> <br /> INSTALLERS CERTIFICATIONs <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br />SYSTEM INSTALLED AT T~E ABOVE ADDRESS WAS CON- <br />STRUL~'~-'D IN ACCORDANCE WITH THE REQUIREMENTS OF <br />THE PERMIT AND T~E RULES OF THE ENVIRONMENTAL <br />TY CO~4ISS ION. <br /> <br /> I have tested the septic tank and certify <br /> it to be watertight. <br /> <br />system was installed by: <br /> ,,l,,~ope~ty Ow~e.r (permite~) <br />[ ] Licensed Sewage DisPOsal Service <br />Signed.-~_ ~ <br />Company name: - <br />(please print) <br /> <br /> (for Marion County use only) <br />The above septic system has been inspected by Marion Co~ty. The info~ation has been dete~ined <br />to be accurate and the system is: <br /> Approved ^ a ' <br /> ~prove~w~ corre~ns: ~ inspection report <br />[ ] Denied { /I ] ~ ~/A ~ , <br />Si~ed: , Title: Date: /{-I ~ . <br /> <br />ts-built, frm ~4/95 WHITE :'~4arion County; YELLOW:Owner; PINK: Installer <br /> <br />~C-15-S41 <br /> <br /> <br />