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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 /> - fi <br /> SALEM O <br /> ---.�. - 503-588-514R <br /> 3-gg- 147 97305 PERMIT NO. J�J (0 - � "IV <br /> MARION �COUNTY .0http://www.co.marion.ors/PW/BuildinglnspectionetkivAjoftqc,50SITE ADDRESS: <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' • T <br /> North <br /> LIU cs PioHO1a'v <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 /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow 3 Gallons/Day STALLED 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: [ ] double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: 1 X(S rl V [ ] flow-through --I'] I have tested the septic tank and certify it to be watertight. <br /> The s stem was installed <br /> Effluent Sewer: Bader Pipe: by: <br /> Size/Mat'1 Size/Mat'l r erty Owner(permittee) <br /> ] Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe [ I Drop [ I Concrete DEQ License Number: <br /> Pipe total depth [ I Distribution [ I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum_ <br /> Curtain Drain Depth_ ` Signed: ' <br /> Effluent Pump: Pump Model o e04 a U6 _ <br /> Pump cycle r <br /> times in minutes; on off'�- s p y'c e Company name:_ i ��`'��- <br /> i,.. . . • I i. _a L .6 i '/�I .�1t� ,'� / ( 1; (J� 1,eprint) <br /> Attacji-im-actditotf—gialeet for components and materials not listed above. Date: _. <br /> (For Marion County Use Onlya above se�p is system has been inspected by Marion County. The information has been d-termi ed to be accurate <br /> and the system is: 1 Approved [ ] Approved with co • 'ins: see inspection report [ ]Denied <br /> Signed: • i_: ,___ # It , Titled • .1 –– ) • if , .. Date: <br /> Oji <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Fore'\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELL W:0 ner;PINK.:Installer <br /> L <br />