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'v 'teaMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> `-- 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> -- <br /> ff ,�n� , <br /> - 503-588-5147 PERMIT NO. <br /> '56-- /9- 000 (6 60 " P�►"`T <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 55'/ /Sa' !l r s +, T" `f <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 'k i'Vi 1 OR 97317 10 <br /> Scale: 1"= ' I?aS1 ( %1 T <br /> \ v t /, North <br /> 9 <br /> tis <br /> v r <br /> _ • Ods <br /> J_ I ^ <br /> Lt. <br /> r -^ <br /> � / <br /> (— Q <br /> 7 / p_ <br /> rh } <br /> o <br /> A-B- 2®P <br /> � 13-u - g7 <br /> , <br /> a-rizz lig <br /> 103 <br /> f. .., <br /> ._ T <br /> oif <br /> J�a6i�6,I <br /> -{ NlL &A. ::L 2 i'-£S <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 /> DO Gallons/Da I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow y STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I 0 0 0 total gallons [] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> p�/ [ 1double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: Ver A IT <br /> Material: 6)C R, [ 1 flow-through I I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: H Header Pipe; yI The system was installed by: <br /> Size/Mat'I 2. Pu C Size/Mat'I �/ l�Z -1 (0 ul I I Property Owner(permittee) <br /> fA Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe N Drop I J Concrete DEQ License Number: <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ �6,317 <br /> Certification Numb <br /> Drainfield Material(Alternative or perf.pipe) <br /> .� a <br /> Total Drainfield Footage 'Y�O Trench Depth Minimum Maximumle i..,__ - <br /> Curtain Drain Depth_ Signed:_ , <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> a / ' n,e <br /> aL`/times innmminutes: on off Gallons per CycleCompany name: c� _ <br /> ATT Make and Model �;J^ (please print) <br /> Attach an additional sheet for c,- .onen and materials not listed above. Date: 5-2/(please <br /> - I g <br /> (For Marion Count Arose Only he above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system i, Of pprov [ ] Approved with corrections: see inspection report [ ]Denied <br /> Signer _��,1�rTitle: y� Cl, Date l 1 1 <br /> MC:S-41 rev /03;4/12;5/14;11/17 G:\Forms\Septic\S-4l As-Built2015Version2017.doc WHITE:Marion County;YELLOW::Owner;PINK:Installer <br /> 1 <br /> il' • . <br />