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-- <br /> MARION COUNTY BUILDING INSPECTION <br /> AllI5155 5ilverton Rd NE <br /> SALEM OR 97305 <br /> MARIQN INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD. <br /> COUNTY �/ (' j (to be completed by system installer) <br /> SITE ADDRESS:_ <br /> G` cJ( ►'1 j71 t'1 t�1Ii°,% ;fir PERMIT NO. .5T c-. 1. —....oO 1 f - I .• 1 T <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM:. ,, <br /> Scale:1"=_ ,�.. <br /> North <br /> A/\,..,... -CA'A.-6717\ ..e.- - , <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: 3 t7 D Gallons/Day . I,HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN <br /> Ud °t1� Mf � STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> Septic Tank:Size: 1 S 6. MaI l Oil t g VV O#- DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size: Mat'I Mfg: I I I have tested the septic tank"and certify it to be watertight. <br /> Alternative Treatment Technology The system was installed by: <br /> if I I Property Owner(permitee) _ <br /> Effluent Sewer:Size: _1 111 Matt PvC- ,Licensed Sewage Disposal Service <br /> Box(es): I I Distribution J:.I-Drop / I I Concrete; J I Plastic DEQ License Number-:3-7 <br /> . - c7 r <br /> ^ <br /> i yyt <br /> Drain ;Material:Header ;Perf: ' DEQ Certification NumberZ �Sy <br /> tt A f e,Ogi !/ <br /> Total Drainfield Footage 'I'U u :Rock Depth:Total: :Under Pipe .;6 <br /> Signed: • Vk/1/1/i - <br /> Alternative Drainfield Materials: <br /> t. // 1, <br /> Trench Depth:Minimum. ;Maximum: b Nat) Lt;Curtain Drain Depth, Company name; In{ CQkISi'.t;ctikU►'I <br /> 1300 c II (please print) <br /> Effluent Pump:Pump Model: ;Static Head in.System Ft' 1�! l/t <br /> Date. .�. / <br /> Pump Cycle Time. ;Gallons per Cycle: <br /> Attach an additional sheet,for components and materials not listed above: . <br /> (For Marion County Use Only) <br /> The above septic system has been inspected by Marion County,The information has been determined to be accurate and the system is: <br /> 1PApproved <br /> • <br /> I I Approved with corrections:see inspection report <br /> I I Denied <br /> Signed: Q""' :bet W c isle: , '1 . `n1L Date; 15 G� g <br /> l <br /> MC;S-91 rev:3/03;4/12 <br /> WHITE:Marion County;YELLOW Owner PINK•Installer. <br />