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Iw <br /> MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> "",�� 5155 Silverton Rd NE to be completed bysystem installer , <br /> ---'4.Z SALEM OR 97305 ( p y ) <br /> 503-588-5147 PERMIT NO, 5 5 5-a---a ?l.o 3P 3- .i"- <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection U_ <br /> SITE ADDRESS:SJ cC / tr�ir Cr <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= 3O' T <br /> North. <br /> `~i ��, ibex �-�.XIS�t� <br /> 1q =New T- <br /> es..0 <br /> 8 <br /> C <br /> a <br /> 6(O <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 /> System Design Sewage Flow Cl JrG Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM.II4- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: LOa° total gallons single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: =v►-cA—StrekAigr- [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: coV [ ] flow-through lave tested the.septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> . . Size/Mat'l Cr( )L 31. 3c3`{ Size/Mat'l I I Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number:_ 37/06 <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: 0 <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum <br /> Curtain Drain Depth_ Signed:_ aC <br /> Effluent Pump: Pump Model <br /> Pump cycle i _ <br /> times in minutes: on off Gallons per Cycle Company name:Accac . t,Q cS���(;_ ye546.. <br /> ATT Make and Model (please <br /> Attachprint) 6 <br /> Attach an additional sheet for components and materials not listed above. Date: 8-7--a-21 <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be a'curate <br /> and the system is: [)4 Approved [ ] Approved with corrections: see inspection report [ ]Denied <br /> Signed: 41Al 0044 Title:€'4' uV ini L r Date: Q <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015 Version2017.doc WHITE:Marion County;YELtOWI:Owner;PINK•Installer <br />