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iiisMARION 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. 55 5 —a-( •G 0 6 e444 9 <br /> MARION <br /> COUNTY http:/Iwww.co.marioaor.us/PWBuildinglnspectioo SITE ADDRESS: 71 bL L a10CSL c ee-,.14.e.-- 1ed-e <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Seiii....i. 012 q-1.305— <br /> Scale:1"— <br /> i 11 North <br /> -}�, J -to' AC, s'7.5.' <br /> 74-1 lei <br /> \-` '_ a 9. *_ <br /> .� 4e <br /> I:(".--" 1,40).-e.... <br /> a A <br /> i <br /> ShyI <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 /> y�7Q GallonslDa I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow y STALLED AT THE ABOVE ADDRESS WAS CONSTRUC1 hD.IN.ACCOR- <br /> TANKSize: Ex(C total gallons [I single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer _, [] double compartment- OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: — [ ] flow-through I ]I have tested the septic tank and certify it to be watertight. NA- <br /> Effluent Sewer: , .. Header Pipe: The system was installed by: <br /> Size/Marl 36341 Pl1C.- sizelMat'l Y�� scan Pt) [ 1 Property Owner(permittee) <br /> (wl Licensed Sewage Disposal Service �. <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe to ~ ( 1Drop idConcrete DEQ License Number: J gl eog <br /> ftpe total depth 12 Distribution [ I Plastic DEQ Certification Number: g.[ <br /> 6 <br /> tDrainfiel Material(Alternative or pert pipe)Total Drainfreld Footage Trench Depth Minimum it Maximum 2L- <br /> Curtain Drain Depth_ Signed:— <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> times in minutes: on off — Gallons per Cycle — Company name: t3 yv(Otis 9fr- Pra'r^ I Z e- <br /> ckplease print) <br /> ATT Make and Model ^' 4 �J <br /> Attach.an additional sheet for mponents and materials not listed above. Date: r- ` <br /> (For Marion County nlv) a above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system' : ( p ed ( (Approved with corrections:see inspection report I I Denied <br /> l�/3 Z.Signed: k I T �/�-'itle: � c _ Date: �� 1� <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:1Forms\Septic\S-41 As-Built2015Version2017.doc WHITE::Marion County:YELL :Ow r;.PINK:Installer <br />