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iikiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. S6 -12 L ' 01 Or U Y-- PST <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 4-33 co v ' -nt.t7------ <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM:' <br /> Scale: 1"=/bi <br /> / t 50 North <br /> ‘N)t)\1\ . / I . , <br /> I' <br /> B-c. �� <br /> t <br /> c,- (3 a�' I ' a� <br /> F _ �� re <br /> 4 <br /> of D <br /> j - <br /> I <br /> IIUOS� t' <br /> i (show all details and dim sions necessary to locate all components of the system in the Tutu e) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> ��s.� <br /> I✓ Gallons/DayI HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM System Design Sewage Flow IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size:_ 1.000 _ total gallons 'single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ) j� double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: �l'mot W [ ] r <br /> Material: C 61n,G�ti [ ] flow-through %4�have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: L4 i i , . Yy / Header Pipe:y I I 1 'l The system was installed by: <br /> Size/Mat'I ,t/`� Size/Mat'] 7 (��� roperty Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(i ches) Box(es) Li <br /> Rock and under pipe ,Drop 1)Concrete DEQ License Number: �9 53 <br /> Pipe total depth I I Distribution I I Plastic DEQ Certification Number: '1 2-9 <br /> Drainfield Material(Altemative oLperf.pipe) 1 -1,F-io c.9/ <br /> Total Drainfield Footage Trench Depth Minimum7A Maximum5D <br /> Curtain Drain Depth_ h/a Signed:__ <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> times in minutes: on • off Gallons per Cycle Company name: 014r6 /' ,n‘,5 u1 Qy.. ] /sb ,, <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for co ponents and materials not listed above. Date: S' — 2 V —23 <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: rtApproved [ I oved with corrections: see inspection report [ I Denied <br /> Signed: .d , rt'itle: t i l VV 10I 4I c Date: Ii� i 2' <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLKJW:Owner;PINK:Installer <br />