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AmMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> Salem,OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. 5,5S"- /!6.00 7/O$ <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection 67,2- ,3 ,(iC /E <br /> SITE ADDRESS: <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: vii9'6 <br /> Scale: 1" = 1' <br /> North <br /> APPROVED AS-BUILT <br /> DRAWING - 5c AI-TALI-ISD <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> System Design Sewage Flows Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> Septic Tank:Size/.5.00 gallons Mat'I 4d1A,/, Mfg iiippirx. DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size gallons Mat'I Mfg <br /> A it�have tested the septic tank and certify it to be watertight. <br /> ATT Make and Model aecivati �Qitum Ar Box(es): <br /> y ,e� � � I I Distribution The system was installed by: <br /> Effluent Sewer:SizeMafl �rlrkl7 { <br /> Ate <br /> I I Drop I J Property Owner(permittee) <br /> I I Concrete <br /> Drainfield Pipe:Size //y[ A1/C I I Plastic �Ir� icensed Sewage Disposal Service <br /> Material:Header Pipe /6 PVC Perforated Pipe DEQ License Number: MAW 31.4177G <br /> Total Drainfield Footage /G0,TTrench Depth Minimum/,Q Maximum_/y DEQ Certification Number: .L, V 73 <br /> Rock Depth:Total Under Pipe Curtain Drain Depth_ n <br /> Signed:_ 7eI?7 //�.�/f IOA)7/I(,/ <br /> Alternative Drainfield Materials Ag",E .rA/F'YLTti /.AAIQ <br /> Ivy., iC 3. ,097 '. ./8"a lFla" cr�✓i4r/v.✓fv <br /> Effluent Pump: Pump Model evermen en tOIRacckT'. / •� Gt, <br /> Pump Cycle minutes minutes Company name:_ <br /> �A�T2�,p,� �6ET (please print) <br /> Time on off - Gallons per Cycle <br /> Attach an additional sheet for components and materials not listed above. Date: 4.... 19- .ZO/9 <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 the system is: <br /> V] Approved ] ] Approved with/ a e_corrections: see inspection report I �Dennied <br /> Signed:fn uctcz= R./ ij2 /S Title: 0/1- 1.1/tea t+-'iz r-47 "e/ta-t Date:`�/l/1«Gin /7 <br /> MC:S-41 rev:3/03;4/12;5/14 WVHITE:Marion County; YELLOW:Owne�PINK:Installer <br />