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r . .. . <br /> MARION COUNTY;BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> �, �. 5155 Silverton Rd NE (to be completed by system installer) <br /> --''7-"r: --` SALEM OR 97305 7� <br /> 503-588-5147 PERMIT NO. F S—c /q`— �'toC96 J <br /> MARION <br /> COUNTY --_, ^ <br /> http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: //J/L/ (rGr i2/— ,__---c <br /> 43= <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=1-0 .. T <br /> r-- <br /> irl �� is °qlNorth <br /> 7 / <br /> ( <br /> '\01. / / <br /> ' '' / 1 <br /> , (V, y '.. .0 / <br /> - ,.. .-,- .,-i--7.--, <br /> ,-- <br /> t c� <br /> ..„,,,,, I <br /> 8 40(, cuu/ <br /> C - ,,kc 1:_-,;7.-D <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 /> Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System1 STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: QTY.) total gallons j}'single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: (r'l;f.7 cWes- <br /> Material: (IC,.—]L.)//,- -/--e' [ ] flow-through ,,1__11 nave tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'I Size/Mat'l I I Pro erty Owner(permittee) <br /> Icensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe 1 I Drop I I Concrete DEQ License Number: S 0/ / _ .. • <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: . <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum___ <br /> Curtain Drain Depth Signed: <br /> Effluent Pump: Pump Model . <br /> Pump e ��/9 j� S <br /> / 0—, <br /> times in minutes: on off Gallons per Cycle Company name:_ L/ 777-7�ATT Make and Model (please print <br /> Attach an additio sheet for components and materials not listed above. Date: _ <br /> (For Mario s .nt U:a Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the syste / ' pproved [ ] Approved w c i e .ions: see inspection report [ ] Denied <br /> Signed: ;. Title: 'fig Date: . / i <br /> MC:S-41 rev: /03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built201 •ersion2017.doc WHITE:Marion County;YE OW.:Owner;PINK:Installer <br />