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1 <br /> i <br /> i <br /> , _. ON COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> - 5155 itverton Rd NE (to be completed by system installer) <br /> ---'-' :fn..--13- OR 97305 <br /> 503-5 8-5147 PERMIT NO. 555-- I R-O 4 fig-13wiw\T- 01 <br /> ,MARION: <br /> COUNTY. 3g 5 3 -i DoE fel/ ®2 <br /> blip://lwww�omarfon.or.ns/PW/Buil 1 ection SITEADDRESS: ' <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale:1"=5?)' I <br /> 'a :; '; t <br /> ,..." _ .- .-. _______' _ North <br /> _1 • 1 l r <br /> 1 ,` <br /> ,11- <br /> j:f <br /> • <br /> r fa <br /> WF!n/:, <br /> ii <br /> Pi <br /> - _ . b.• '` ; E <br /> 1 1,___ ____----1.---'. _ t. `,A j.. .. i. <br /> t <br /> • <br /> s <br /> i <br /> • <br /> A(2.Pr4- <br /> 4i*1—o4.1( ceplw4e.Y+a4 -only <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM>j1YATER1AIS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> Design Sewage Flo* GallonslDay I HEREBY CERT1 Y THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT TELE ABOVE ADDRESS WAS CONSTRUCTED INACCOR- <br /> TANK Size L 000 Vial gallons VI single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> 1 OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> r.Leal dl't..e.,..- Ca 4• 01esa. 1 ] double compartment <br /> Material: to At.i-a}e. <br /> ( ] flow-through IA I have tested the septic tank and certify it to be watertight <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mall Size/Mat'1 1 1 Property Owner(permittee) <br /> 1/I Licensed Sewage Disposal Service <br /> DRAINTIELD rock depth(inches) Box(es) +� <br /> Rock and under pipe_ I 1 Drop I J Concrete DEQ License Number: Z 36 - O3 <br /> Pipe total depth I 1 Distribution i I Plastic DEQ Certification Number: <br /> Drainfield Material(Alternagve or pod.pipe) <br /> Total Dralnileld Footage Trench Depth Minimum Maximum <br /> Curtain Drain Dep Signed:_ E • 17 e 1.4e_...--) <br /> Effluent Pomp; Pump Mod 1 . <br /> Pump cycle <br /> times in minutes: on off . Gallons per Cycle Company name: LorL O �,1 i r1 eict.0 J,�':a..3ATT Make and Model 1 (please pr t) <br /> Attach an additional sheet r-• moments an,materials not listed above. Date: 4/[ <br /> (For Marion Conn' . .a Only) The,•ove septic system has been inspected by Marion County. The in onnation has been determined to be accurate <br /> and the system is: st r proved [ 1 Approved with corrections:see inspection report [ 1 Denied , <br /> n <br /> Si:n-•• % _, Title: f` Date: .Li .2 I 1 <br /> MC: -41` 3/03;4/12:511 ;11/17 G:\Forms4Septic4S-41 As-Bui112015Version2017.doc WIRJTE_Marian Cmmry:YELLOW_•Owner;PM:installer <br /> 1 <br />