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MARION COUNTY BUILDING INSPECTION . <br /> INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> ,; ,. ,�, 5155 Silverton Rd NE (to be completed by system installer) <br /> - SALEM OR 97305 <br /> ): pN503-588-5147 PERMIT , 55'® 2,0 -• 004 . —-_— <br /> :COUNTY hftpa/www.ro.marinn.onus/PVI'lBuildingtnspection <br /> sin ADDRESS: 1io . woo 4zp SE�_4. oms <br /> AS-BUILT PLAN OFA CONSTRUCTED SYSTEM: <br /> Seale: 1"_ ' is Wel ` <br /> W North <br /> \ ,-% .•f • —P. \ <br /> _, r <br /> . A7) d :4,' \ CO <br /> `�' 6 0... A <br /> a - E tr,4 2' ; I ... <br /> 4 <br /> 1 -1- \ , i a° . He)" Q'''' <br /> , <br /> q <br /> iF. <br /> } Va.'. <br /> S <br /> rte..="'" 4 <br /> I. (show all details and dimensions nee ssary to locate all components of the system in the future) - _� �__ <br /> ! SYSTI M•MATERIALS AND'�SP1 CII ICAs IONS: INSTALLERS AL,t I RS C ISR 11FI(A 1 IC)'�,_: I <br /> ! System Design Sava{e Mow Gallons/Day 1 I Il RIa)1 CERTIFY Y THAT I Ill ON-SITE SE VAGli SYSTEM IN- <br /> SystemSTALLED AT TIlE ABOVE ADDRESS WAS CONSTRUCTED IN ACC'l)R- <br /> `4 "t'ANIC'Size: / C)0 C. total gallons 1 I single compDANCE wrriI TI Ili REQUIREMENTS OF TUE.PERMir AND THE 121.11,ES <br /> 11 Manufacturer: I double cuntlinrtmcnt <br /> L_Y__. ()f:THII:ENVIRONMENTAL(RiAl,rl 1 COMMISSION. <br /> tvtaterinl: l I Ilow.Ihrnugh I have tested the septic tank and certit'y it to he watertight. <br /> Effluent Sewer z{k' h, (Leader Pipe: The system was installed by: <br /> Size/MaCl `l 2U.7 S.izeimar I ,......-------,.---.. _. . ...... I I Property Owner(permillee) <br /> . }p}Licensed Sewage Disposal Service <br /> 1 DRAI\PIELD rock depth(inches) Bns(es) !�� 11 Zit 1 <br /> I)I Q I,icease Nttmber: <br /> Rock and under pipe _J _____.-_ �I)rup ix:,,,,,,,,,,, _.....___.._._.__.._ _.._____..._.. .. ........_ ._.._ <br /> i Pipe total de th - I I Distrihulicm I (plastic <br /> 577 <br /> • - I)F,I7 Certification Number: <br /> El I)rtfinlield Material(Alternative or pert:pipe) <br /> Total Drainfreld Footage,,4o '! 'french Depth Minimum Zit MMaximunt, <br /> N <br /> Curtain Drain DepthSigned:, / • <br /> ,._. <br /> I Effluent Pomp:Pomp Model_ <br /> Pomp cycle �-' <br /> times in minutes: on__ off._ Gallons per Cycle C'ontpatn'name:____ ^ ✓L_ q(/u <br /> v'--4646phia/16------ <br /> ATT Make and Model (plcest print) <br /> Attach nit additional sheet for components and.materials not listed II bore, Date: L G v-' <br /> (For Marion Cot ntv Use Only) The above septic system has be inspected by vita ion C'iu nay. The information has:been.de termined to be accurate <br /> and the system is ,pproved I I Approved With co rec�tions::see inspection report I l Denied <br /> Signed. _ Title- .CO S l9 Date: Z ( 2( <br /> MC':S-11 rev::3/03:4/12:5/14:11117 (i:\FurmslScptic\S-4 f As-lluitt20 1 SVersion2017,doe 11/Ill E Morion l.'ntnrt': )'ELWI$Ownei:PiA`i:Installer <br />