Laserfiche WebLink
h� MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> .1.. SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. .57.55.- / 00 0S 647 -PeMT <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection Z 374, & _ .f. fir," <br /> SITE ADDRESS: �i <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Sa r l e al <br /> Scale: 1"= SO' 4 <br /> __.__._._... __. -• North <br /> . / /T•' <br /> �S/ to <br /> • ,i s�_''�� ,� - c . H H o• , <br /> ;�! . � f (3 - G. l 26 <br /> -Lam_, . F g 2 <br /> _ o <br /> N <br /> NI Ito' Q — F- —^ -2 2 r <br /> i3ot <br /> C R <br /> (sihow all details and dimensions necessary to to ate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> Sy•em Design Sewage Flow �,�d Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> N. TANK Size: 110 pv total gallons [+Q single compartment DANCE WITH THE OF THE ENVIRONMENTAL QUALITY OCOMMISSION.YF THE PERMIT AND THE RULES <br /> Manufacturer: Wr1 i 1 [ ] double compartment <br /> " Material: noel r [ ] flow-through I I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer Header Pipe: it The system was installed by: <br /> Size/Mat'I II r PVt� Size/Mat'l di Ica el I I Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Boxes) <br /> WG\1 Rock and under pipe n Drop Concrete DEQ License Number: J 6 I 8 • <br /> Pipe total depth I I Distribution I I Plastic (� <br /> DEQ Certification Number: 0 3 <br /> Drainfield Material(Alternative or perf,pipe) E Z--n�1Ot•./ <br /> Total Drainfield Footage LI-!0 Trench Depth Minimum 211 Maximum TA <br /> Curtain Drain Depth Signed:_ OerPtej f <br /> Effluent Pump: Pump Model . <br /> Pump cycle ,` <br /> times in minutes: on off Gallons per Cycle Company name:_ Q al �/I1 G <br /> ATT Make and Model (please print) J <br /> Attach an additional sheet for components and materials not listed above. Date: 7/2t (2.2 <br /> (For Marion Cou tv Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: pproved [ I Approved with corrections: see inspection report [ I Denied �J <br /> /22 Signed: - - Title: t-t+� / b,5 T (�its G Date: <br /> MC:S-4l rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-4I As-Built2015 Version2017.doc WHITE:Marion County;YELLOW::Owner;PINK:Installer <br /> /" . j <br />