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F' . <br /> b� ' MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> -"ht.-4.'. <br /> " y•� 5155 Silverton Rd NE (to be completed by system installer) <br /> '1--"^--��= SALEM OR 97305 � ClJ O o� ��G I V <br /> 1-- 503-588-5147 PERMIT NO. _ <br /> CMARION <br /> LINTY http://www.co.marion.or.us/PW/Buildinglnspection 2Z ,�.ei �� '0-e:SITE ADDRESS: �,OZ �• <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: --1-- <br /> e�„ 0 �' �' ] <br /> Scale: 1"= ' 1' <br /> North <br /> ,...----� <br /> Ks , <br /> 2r <br /> UX . <br /> GD 3 <br /> LN S � <br /> -73% <br /> 70 ' <br /> 6 R' / <br /> E-/ts-t-1 Diat.(42a, 7, <br /> ,. <br /> $/9 . <br /> too0Grt,1_ CM A la k Eserg BcAtiCiel <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 4'15'e Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /000 total gallons [X single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> � <br /> Manufacturer: U00 double comP[ ] <br /> Material: (00,C„r [ ] flow-through I 1 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer:�1 Header Pipe: The system was installed by: <br /> Size/Mat'l eI ' A-ZZ.4 Size/Mat'l .2,.i KCI►.. QvL 5c1,LO [?(Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I ]Drop I I Concrete DEQ License Number: <br /> Pipe total depth 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:_ ci,,..4J.,_______ <br /> Effluent Pump: Pump Model CV CO-C`'/P ,3 Uv <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle - Company name: <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for corn.o.• :Id materials not listed above. Date: g— t5 <br /> (For Marion County Use 2 nl ) Th above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: ;It]Ap turd [ ] Approved with corrections: see inspection report [ I Denied <br /> Signed: Title: '` �V X"V Date:AA(3 <br /> MC:S-41 rev:3/03;4/1"5/14;11/17 G:\Forms\Septic\S-41 As-BuiIt2015Version2017.doc WHITE:Marion County;YELLOW:Owner;PINK:Installer <br />