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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> --4------ 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> -- 503-588-5147 PERMIT NO. /9--c o An t <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 106 6/ S-21 ,,.vt u„tat <br /> �...... <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> e o, <br /> Scale: 1"=1:05' -50 l'," - !;• T J <br /> •. North <br /> •• 17/1-- — <br /> • <br /> Fed . <br /> a e <br /> _...,,A , <br /> 4...k <br /> AC= Z`7' <br /> via <br /> [3 c - Liz <br /> A- 17 - 13-1 <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 /> Sewage Flow I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design g g Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: ].( }ej total gallons X single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: Wei.,Te [ ] double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: (to e,rc4, [ ] flow-through Qq I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'l a� 54.KC/pdc_ Size/Mat'l y" PV( I I Property Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe ( " p(j Drop I I Concrete DEQ License Number: �dg <br /> Pipe total depth I7 i' I I Distribution I I Plastic - <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) peso <br /> Total Drainfield Footagerte-OO Trench Depth Minimum Z'i Maximum's" ," <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model - - - _ - <br /> Pump cycle <br /> times in minutes: on - off -- Gallons per Cycle Company name:rl!@tel- `—Ovroi _ 2-4-e..._ATT Make and Model rJ (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: —g---11 T <br /> (For Marion County Us• 'i n v The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is:rr pprove, [ ] Approved with corrections: see inspection report [ ] Denied <br /> Signed: ' Title: Date: CJ 1a 1l <br /> MC:S-41 rev:303;4/12;5/14;11/17 G:\Forms\Septic\S-4l As-Built2015Version2017.doc WHITE:Ma-ion County;YEL OW: wner;PINK:Installer <br />