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isi <br /> r" MARION cowry BU[LDRVGINSPECnON INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> DIVISION (to be completed by system installer) <br /> ilif <br /> rem 555 Court St NE/PO Boz 14500 • ���+++yyyS ^ G....) e----e----e USTY Salem OR 97309-5036 <br /> (503)5813-5147 SITE ADDRESS: �/ L�Jr/ <br /> )SICI Air <br /> PERMIT NO. 0 '/ , / ! 5 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> " i <br /> _ T : — ` <br /> scale: 1" = 1 <br /> North <br /> I <br /> A 4 o c z 1,3 ` \ <br /> a�O..�i0n a-Ar.r' AxisC <br /> Q -to c : /03 35-1 ,JAVS • <br /> A 4_o c1 /bs' of out. , <br /> la <br /> -.7 bey',( ox b `" ch we 1{ <br /> E. recti r+� F. I a. <br /> C ,� g J,- <br /> � �aC— $ ice � <br /> V- I. El <br /> o C "t7 -- <br /> .-- p.2, --/Q...S- 1 <br /> ' / <br /> r r cJ .1 ` - <br /> .A <br /> ._ <br /> __ - -.• I ,.- <br /> ..... <br /> ./ ~ <br /> ,O I.... <br /> ` <br /> � <br /> 7„13-.1 <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIrICATION: <br /> System Design Sewage Flow: ` 1✓ Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br /> �e () /_ „ ; /- SYSTEM INSTALLED AT THE ABOVE ADDRESS UI WAS CON- <br /> Septic Tank, Size: CJ Mat'l: Mfg: (�J`fJ� 1 STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br /> THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br /> Doming Tank: Size: Mat'l: Mf QUALITY COMMISSION. <br /> Effluent Sewer: Size: <br /> 4/ U 1-4— I have tested the septic tank and certify <br /> Mat'i: 3 it to be watertight. <br /> Bow(es): 1 3 Distribution; 14 Drop / J/A Concrete; [ I Plastic The system was installed by: <br /> // C I Property Owner (permitee) <br /> Drainfield Pipe: Size:4:3r ; Material: Header:�� _ ,• Perf,2029 1-4—Licensed Sege Disposal Service <br /> Total Drainfield Footage:f0 ; Rock Depth: Total4'; Under pipe:( r� DEQ LicensiNumb= • 40... <br /> /1G� / <br /> Alternative Drainfield Materials, ` <br /> Signed: i_ ...��.�1�4 f� <br /> Trench Depth: Minimus L/ ; MaximueR 5/ ; Curtain Drain Depth:h� ` T <br /> ` ..e. <br /> Effluent Pump: Pump Model: �` ; Static Head in System; "" Ft. Company name: . L . <br /> [please print <br /> Pump Cycle Time: `_ ; Gallons per Cycle: •�" - /7-0 <br /> Date: <br /> Attach an additional sheet for components and materials not listed above. <br /> — - L , 1 <br /> (for Marion County use only) <br /> The above septic system has been inspected by Marion County. The information has been determined to be accurate and <br /> system is: <br /> Approved <br /> ( ) Approved with corrections: see inspection report <br /> [ ) Denied <br /> A �j� <br /> SignOirr �`� Ti 'e: a "! / Date: e /X <br /> MC: S-41 . . WHITE;Marion County; YELLOW:Owner; FINK:Installer <br /> rev: 8/00,6/01 <br />