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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> �, 5155 Silverton Rd NE (to be completed by system installer) <br /> --.0---...-..-_-,, SALEM OR 97305 _ <br /> MARION_ 503-588-5147 PERMIT NO. 5 5 5- l - 000S0 'e,I v <br /> COUNTY <br /> http://www.co.marion.or.us/PW/BuildingInspection �...�-A <br /> ~iV� <br /> SITE ADDRESS: L� t 3 �J�'�^ — <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' T <br /> - North <br /> , i <br /> . L <br /> • <br /> • l I ii <br /> . <br /> I L <br /> t/ /r <br /> r / <br /> l <br /> ® or // <br /> C ' / <br /> 1111 <br /> / <br /> tkewse- <br /> c 0 <br /> C3- -� A--0., _ fob <br /> G- .a7.u, FA-ST <br /> p— 9,-> to y,,,• <br /> E — co,--,•vrG% ,e <br /> - - - - - -e-sissA--'%• 2--vc. . .. <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 /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: [ 1 double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through WI have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'1 Size/Mat'l I ]Property Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I J Concrete DEQ License Number: 37 q 0 8 <br /> Pipe total depth I I Distribution I I Plastic , <br /> Certification Number: I G 3 a <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage - Trench Depth Minimum Maximum �r/� <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle a,c �C.— <br /> Company name:_,/`�1.S�p_ �� r f <br /> S <br /> ATT Make and Model 0-5 /"`:GSU c sq. (please print) <br /> Attach an additional sheet , i mp r ents and materials not listed above. Date: g" a 1 - L4 _ <br /> (For Marion Co tv Use On i) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system i.: Itil • s pr I -ed [ I Approved with crrections: see inspection report [ ]Denied s� <br /> Signed: Title: �'•"� Date: Vt t <br /> MC:S-4l rev:3 43;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW:Owner;PINK:Installer <br />