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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> gliki <br /> 5155 Silverton Rd NE OR97305 (to be completed by system installer) <br /> _ <br /> 5 3-SALEM84 PERMIT NO.01 "G ( 0 CD T st I 1 R r r ," 1 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection Sr-SITE ADDRESS: � �� J� 7 e+�,,���,,� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: t�"'"`'r r 1 <br /> Scale: 1"_ ��. , _ T <br /> ,0 i North <br /> vt I0�s. _ <br /> q‘Jc-- ? <br /> iv '9z4 <br /> 5 0 <br /> • <br /> C -. <br /> N iig as I ys_ <br /> / :' <br /> G <br /> I/O ' /0' C's <br /> 6',-,(A kICK Vat ` c- ,' <br /> _ <br /> NI-.) � L'� on�OU, S� tvvK <br /> 19L�� , <br /> TA V\K 19()W- Q(!ti /soo �� K <br /> • PIA r� Sys � as, �� [ �� i <br /> (show all details and dimensions necessary . Ilcate 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 Flloow Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: J 0 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: Uri4;1 et1-prpor <br /> double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: )0/,,A•L [ ] flow-through [ I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mall` J �p/je.„, Size/Mat'1 Property Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> .Rock and under pipe I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum <br /> Curtain Drain Depth_ _ -- <br /> Effluent Pump: Pump Model ,Z,t5e..f((er- <br /> Pump cycle it , <br /> times in minutes: on /2 off y ' Gallons per Cycle DaameLed Company name: <br /> / (please print) <br /> ATT Make and Model/CC S 2G 7 s e it,,,_,C! <br /> Attach an additional sheet for components and materials not listed above. Date: e-3 a9`2 <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:Approved ( I Approved wi corrections: see inspection report I I Denied <br /> Signed: �\ Title: Datee:_ L/ <br /> )-3 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />