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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> ggs 5155 Silverton Rd NE (to be completed by system installer) <br /> SA5 3IEM OR-588_ 14 97305 • <br /> PERMIT NO. Z\-000(41i' <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection 1� (` „ j C O B r ° Sc .,/,j <br /> SITE ADDRESS: 3�K /�/� �LI �l/ifd�r � . �""'S <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> S �I� Devon <br /> Q <br /> Scale: 1"_ ! 1' <br /> 0q North <br /> 4/� � <br /> t <br /> zi <br /> S <br /> t Is. <br /> {-goose N.], <br /> lI „ <br /> ox-> - -/ d0 <br /> D-3 . <br /> rfbl ,y <br /> 6a' —'1 <br /> l! 110' <br /> 1' <br /> . , <br /> 1. i <br /> AdISIEWAIEWIELIPMEMP ' .,.% ,,<.:,\ a ,...*.:-:g 4_41i ....-s,- <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: p a ex) total gallons .single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: 01Lt.t•Jc , [ ] double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: Pt3�Ql};_1.4 5 [ ] flow-through ( I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: el <br /> Header Pipe: tt The system was installed by: <br /> Size/Mat'l ! A 5-S Size/Mat'l 1 ?ro434 I I Property Owner(permittee) <br /> iyl.kigensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe jig Drop (id Concrete DEQ License Number: 3 Ce 0 V <br /> Pipe total depth pp'" I 1 Di$tribution I I Plastic DEQ Certification Number: : Z'0 <br /> Drainfleld Material(Alternative or pelf.pipe) L&5..( -.C.w 09 <br /> Total Drainfield Footage'17. Trench Depth Minimum It4 Maximum VI <br /> Curtain Drain Depth_ Signed:_ <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ [ j10 - V--00(fi _— <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. ,.Date: Os-1�-ZQZ` <br /> (For Marion County U d'Onl The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system i : [ rove [ I Approved with corrections:see inspection report [ I Denied <br /> Signed: Title: ®te--) S. - Date: (F12 10( <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 />