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, <br /> h MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> "'•" 5155 Silverton Rd NE (to be completed by system installer) <br /> "^-`f- SALEM OR 97305 <br /> 1� <br /> ---AA ,3" ®-. - 503-588-5147 PERMIT NO. 3 30 — M T <br /> 'MARION . <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 9 I 5 9 vQ ne), eta. i'C <br /> AS-B JILT PLAN OF CONSTRUCTED SYSTEM: '`reicr- <br /> Scale: 1"= 60 4' T <br /> Ll u Sod, tb o North <br /> too' <br /> 4--c,; 12q ' <br /> M dug` I _ <br /> e - c s d II/ f <br /> . .„. 6- — p, 9I '6 a� <br /> P v 1T , e - D 1 ®G e 6 ff <br /> P 1 t��c sil <br /> _C <br /> v. <br /> .1 . <br /> is <br /> 00 <br /> \�" - K ca <br /> 0 �,�' 13 <br /> t p L <br /> e ; 47� <br /> jP' Vo - (-fr., <br /> �tsT <br /> t2® 1B6• <br /> t`, tzo 2'' <br /> vzo la <br /> 'ill� ��yd I 1 Zo - <br /> +4 0 A 6,,,ic------------- - - - - -__ __ <br /> SG' _ 701 <br /> 30 / <br /> __ _______________________ _____-- <br /> V'.I 1 t y wON• <br /> (show all details and dimensions necessay 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 Z� Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANKSize: 5e0 'I total gallons [ single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: WcL1 f <br /> [ ] double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> [ ] flow-through ---- [)cj I have tested the septic tank and certify it to be watertight. <br /> Material: Cow«e� <br /> Effluent Sewer:if Header Pipe: /� The system was installed by: <br /> Size/Mat'l If 30311 Size/Mat'l 11 3e 311 I I Property Owner(permittee) <br /> [K1 Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) . <br /> Rock and under pipe Drop ®Concrete DEQ License Number: 3 L 15 tp <br /> Pipe total depth I ]Distribution I I Plastic <br /> DEQ Certification Number: B 3. <br /> Drainfield Material(Altemative or perf.pipe) c 2—k JOw <br /> Total Drainfield Footage S-10 Trench Depth Minimum 2.,1 Maximumti?e, / <br /> Curtain Drain Depth Signed:_ J e, <br /> Effluent Pump: Pump Model . <br /> Pump cycle / <br /> times in minutes: on off Gallons per Cycle Company name: c3 1 . el.V441 h5 <br /> ATT Make and Model / (pl1easeprint) <br /> Attach an additional sheet for components and materials not listed above. Date: 7/ Z//ZZ <br /> (For Marion County e Only) The above septic system has been inspected by Marion County. The information'has been determined to be accurate <br /> and the system. •- [s ' •pr sJ ed e [ ] Approved with corrections: see inspection report [ I Denied <br /> Signed: _ d , `. Title: ( Date: ' , <br /> MC:S-41 red:3/03;4/12; )114;11/17 G:\Forms\Septic\S-41 As-Built201SV'ersion2017.doc WHITE:Marion County;YELLt1W.•Ow1er;PINK:Installer <br />