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"ti..� ' MARION 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. 20" O 7 'O 6, 3 6 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection 9 3 7 �� <br /> SITE ADDRESS: 6� �/ � rla..n <br /> �AsJ _><0t.`j <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ ' T <br /> C______„,....... . <br /> North <br /> 4 <br /> TWAIi ....._____.____...-- <br /> I/ I 5 <br /> 3J <br /> /� s 1g. <br /> o.� Aia Sp r <br /> 5 k4' 1 <br /> So ' <br /> I <br /> _....*•-•'-f--":1../...._,A_V--- <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 /> Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: l(SLX-7 total gallons [mangle compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> �} d- [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: ,'...'"—<- [ ] flow-through I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: tl Header Pipe: The system was installed by: <br /> Size/Mafl 4) ti e-4' ✓ Size/Mat'l I I Property Owner(permittee) <br /> e;:auvultylactI> Licensed Sewage Disposal Service <br /> DRAINFIELD ""d rock depth(inches) Box(es) <br /> Rock and under pipe 11 I I Drop I I Concrete DEQ License Number: d��U 1, <br /> Pipe ` <br /> total depth I Lc Distribution I I Plastic <br /> DEQ Certification Number: j 3.1 <br /> Drainfield Material(Alternative or perf.pipe) VOL, <br /> Total Drainfield Footage Trench Depth Minimum 211 Maximum_ <br /> Curtain Drain Depth_ Signed:_-61 <br /> Effluent Pump: Pump Model_ PI� 60 . <br /> Pum cycle <br /> times in minutes: on offf Gallons per Cycle Company name:_ l^�`A�Pi Lre"�.-S ate vc.t <br /> ATT Make and Model )A �T ‘5y (please print) <br /> Attach an additional sheet for components and materials not listed above. j l IJY/` Date: ® . 0 <br /> (For Marion County Use Only) The above septic system has been inspected>vIarion County. The information has been determined to be accurate <br /> and the system is:,M.Approved [ ] Approved withpp� corrections:`�a�� see inspecttion report [ ]Denied jc9 <br /> � <br /> Signed: V P 1 AM:Lik Title: G J—V V l D 14 pe9 a- Date: <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELL W:Ownir;PINK:Installer <br />