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- INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />scale: <br /> <br />(show fall details and dimensions necessary to locate all components of the system in the future) <br /> <br /> size: ~ <br />~ewer: size: ~ II <br /> Distribution; ~ Drop <br /> Pipe: Size: "--~ <br /> <br />SYSTEM M~TERIALS A~{D SP~CIFICATIO{{S~ <br /> <br /> Mat'1: ~ Mfg: <br /> <br /> / ~ Concrete; <br /> ; Material: Header:~W! <br /> <br />[ ] Plastic <br /> <br />To~&1Dr&~mf~old F~tlga,~O; ]U~:k D~p~ Total:__; Under pipe: <br /> <br />Zf£1uent Pm~ Pum~ Model: e--- ; Static Head ~n System: <br /> <br /> Pump Cycle Time: "''-- ,,. ; Gallons per Cycle:--'"* <br />Attach &n a~itioaal sheet for cem~on~nts aa~aterials not listed above. <br /> <br />ft. <br /> <br /> IN~T~ r-r-~m$ CERTIFICATION ~ <br /> ! HEREBY CERTIFY T}{AT THE ON-SITE SEWAGE <br /> S~-~'£~ INST~T.T.~-D AT THE ABOVE ADDRESS ~AS CON- <br /> STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS ~F <br /> THE P~RMIT AND THE RULES OF THE ENVIRONMENTAL <br /> Q[XALITY CO~4ISS ION. <br /> X have tested the septic tank and certify <br /> it to be watertight. <br /> <br />rThe system was installed by: <br /> [ ~ Property Owner (permitee) <br /> Licensed Sewage Disposal Service <br /> <br /> (please print) ' ' 6 <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 <br />[ ] Approved with corrections: see inspection report <br />[ ] Denied <br /> <br />Signed: <br /> <br />Title: Date: <br /> WHITE:Marion County; YELLOW:Owner; PINK:Installer <br /> <br />~s-built.frm 4/95 <br />MC~15-S41 <br /> <br /> <br />