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MARION COUNTY BUILDING INSPECTION gill <br /> 5155INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> _ 5155 Silverton Rd NE (to be completed by system installer) <br /> 5 3-88 514 97305 PERMIT NO. �,J 5 5 "c21-'D f/li/ <br /> MARION <br /> t COUNTY htt //www.co.marion.or.us/PW/Buildin Ins ection NO 1�/�G)'0(,�o�� <br /> P� g p SITE ADDRESS: � �rd <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= 11617(j) T <br /> . North <br /> . iLe/A—,—...0.7 <br /> ./ t <br /> 00.9' <br /> O <br /> e '3' /..) <br /> diriCC I 0( <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 /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow -tL Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: • IS <br /> t -total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> R / [ ouble compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: /�97� <br /> Material: ` /(�/I (1/ (1 J [ flow-through eve tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: r t/` ,�.//,, Header Pip �^ �. he system was installed by: <br /> Size/Mat'l i /f mI eil `1'U Size/Mali LP �.70� t Prperty Owner(permittee) • <br /> 1 1 Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe 31p IV, I I Concrete DEQ License Number: <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Altemative or perf.pipe) <br /> Total Drainfield Footage//® Trench Depth Minimum yO Maximumq -' ,z'cici <br /> Curtain Drain Depth ,�_ Signed:_ y � � <br /> Effluent Pump: Pump Model WC. LL �p�`�'I(I_ <br /> Pump cycle ,C1‘..v\z/ <br /> ,l <br /> times in minutes: on Goff nn Gallons per Cycle 8 v Company name: <br /> O <br /> ATT Make and Model I:6 CO/it'll( ( l (please print) <br /> Attach an additional sheet for, mponents and materials not listed above. Date: <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the sys em is; 7+Approved [ proved with corrections: see inspection report I ] Denied <br /> Signed: I Title:PIA)A) (OI Lt > Date: <br /> MC:S-41 rev:3/03;4/12;5/14;11 17 G:\Forms\Septic\S-41 As-BuiIt2015Version2017.doc WHITE:Marion County; YE LOW: vner;PINK:Installer <br />