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i <br /> ' <br /> MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> ", 5155 Silverton Rd NE to be completed by system installer) <br /> .. .,<':` Salem,OR 97305 ri, <br /> MARION 503-588-5147 PERMIT NO. 1 —1 OD '2 2. <br /> COUNTY <br /> http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: I ( V&e.ci\ & 4- sty <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= T' <br /> North <br /> I <br /> z, 5 ..........„.....4 <br /> � a <br /> i' 5 5, <br /> s <br /> i-10 inkie <br /> H late Ls-1-- <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 Flow 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/00 gallons Mat'I rP vlfg t��+esk.1-h S 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 /> [have tested the septic tank and certify it to be watertight. <br /> ATT Make and Model Box(es): <br /> it I I Distribution The system was installed by: <br /> Effluent Sewer:Size '9 Mat'I pµ' V I I Drop <br /> [ I Concrete [ ]Property Owner(permittee) <br /> Drainfield Pipe:Size Plastic [I–Licensed Sewage Disposal Service <br /> Material:Header Pipe Perforated Pipe DEQ License Number: 3 7e27 623 <br /> Total Drainfield Footage Trench Depth Minimum Maximum_ DEQ Certification Number: L5 t ® '('O <br /> Rock Depth:Total Under Pipe Curtain Drain Depth �{� r <br /> Signed:� W <br /> Alternative Drainfield Materials <br /> Effluent Pump: Pump Model • Company name: l,(,Vd� p k1Ae� &e...114-►(...+ <br /> Pump Cycle minutes minutes (please print) <br /> Time on off Gallons per Cycle <br /> Attach an additional sheet for component -•. Is not listed above. Date: k(—Lk— Pi <br /> (For Marion Count .se Only) <br /> The above septic sys - has been inspe•. ed by Marion County.The information has been determined to be accurate and the system is: <br /> -4,r"roved..e>,,.,.....„0-0' ppri •d with corrections: see inspection report I I Denied <br /> Sign-.• Tirlp4.61ir Date: A i 1� <br /> MC:S-41 rev:3/03;4 ;5/14 WHITE:Marion County;YELL W:Owner;PINK:Installer <br />