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gibMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> 5 3-SALEM <br /> OR 97305 PERMIT NO. 54,55""Q 3 "®V,goo <br /> MARION 6 <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection SITE ADDRESS: "C� �, 1 6'877 \1 11 Y 4 e1dt�° <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: I VrUs.' Ok <br /> Scale: 1"=35 ' /;/ %to pC�111Q i 1' k T <br /> v J North <br /> 17 r <br /> CO • <br /> 'Q <br /> L. <br /> / <br /> 3 ' <br /> 10 properf7 iy‘e. <br /> Its <br /> lay <br /> a e 31 [ i Septic 14AK <br /> VII <br /> i 10 From House + <br /> TcloK <br /> i'5° j aVa. <br /> Rouse <br /> Vq l I'e./ View Rd <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 /> System Design Sewage Flow 9,5V Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: b o total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES[ ] double compartment <br /> y OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: Q r� <br /> Material: Corset, e [ ] flow-through [ I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Il ` ,.„ Header Pipe:9 Il The system was installed by: <br /> Size/Mat'I ' $an I d DWV VSize/Mat'l .,7�,? bd Property Owner(permittee) <br /> [ [ Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe 6 Drop IX Concrete DEQ License Number: <br /> Pipe total depth l 2 ii I_I Distribution I I Plastic <br /> DEQ Certificaf Number: <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage 40 Trench Depth Minimum.29 Maximum®_ <br /> Curtain Drain Depth Signed. _ _ 1 !"/. :` <br /> Effluent Pump: Pump Model . I1✓ <br /> Pump cycle L <br /> times in minutes: on off Gallons per Cycle Company name: <br /> ATT Make and Model I <br /> (please print) <br /> Attach an additional sheet for components 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 system is: [ i Appr [ ] A d with corrections: see inspection report [ 1 Denied <br /> Signed: \ Title: ‘'‘ 5 ' ( 33 Date:CWg tic, `7,-3 <br /> MC:S-41 r :3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County;YELLOW:Owner;PINK:Installer <br />