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4* MARION 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 /> 503-588-5147 PERMIT NO. 'dW otip5.1 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection SITE ADDRESS: �f W at/x- <br /> T.h, Af*-- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' T <br /> North <br /> /4-1111-014 <br /> ' .,3XA tjt-- ne 11 C. VI'jY1/1 <br /> °-4/4-Nil <br /> . Crtn— 14T7P- 61‘1 <br /> 1 1111111171 <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 /> � <br /> i �� <br /> G I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow ° ":2) Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: total gallons .ingle compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> AR.ff.p..44,3L <br /> [ 1 double compartmentOF ave tes RONMENTAL QUALITY COMMISSION. <br /> Manufacturer: �_J�1/ <br /> Material: r [ 1 flow-through [ have tested the septic tank and certify it to be watertight. <br /> Z/ if The s m was installed by: <br /> Effluent Sewer: Header Pipe: 4. <br /> Size/Mat'l Size/Mat'l I roperty Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inch s) CP <br /> Box(es <br /> CP <br /> Rock and under pipe [ rop I 1 Concrete DEQ License Number: <br /> Pipe total depth 1N I )Distribution I I Plastic <br /> .. d <br /> /� DEQ Certificatio- 1 mber: I 4 <br /> 4 <br /> Drainfield Material(Altemative or eri.pipe) Z (4L6 ^-1:2 firTotal Drainfield Footage�" Trench Depth Minimum Maximus <br /> • <br /> Curtain Drain Depth . Signed:_ D <br /> Effluent Pump: Pump Model \ <br /> Pump cycle <br /> times in minutes: on off _ Gallons per Cycle Company name: y tQaZ r--.• 13.C./f e.% <br /> ATT Make and Model (please int) <br /> Attach an additional sheet fo omponents and materials not listed above. Date: CO Z..— <br /> (For <br /> (For Marion Count se Onl The above septic system has been inspected by Marion County. The informati n has be determined to be accurate <br /> and the syste 's: [ Ai rtk ed [ I Approved with corrections: see inspection report [ I Denied <br /> 416.71: ! P <br /> Ir <br /> Signed: t' l U �("—� Title: e WI Date: �d O- e <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE.•Marion County;YELLOW:Owner;PINK:Installer <br />