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dillMARION 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. 695 Z2 ct:s (:c 2, <br /> MARION <br /> COUNTY htt •//www.co.marion.orus/PWBuildia ton <br /> p• ��i SITE ADDRESS: 1'V---/—i ',...Ze{ S t 1 uz:,,:�,-, 12c11 AJE <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: TCi.IA, t�A S (t crr,,.-tom-, 1G-✓L �i"?3g-1 <br /> Seale:1"= ' T <br /> North <br /> le <br /> `w 411. <br /> ,- <br /> IAA <br /> e <br /> , 14M (//t--,/ <br /> (show all details and dimensions necessary to locate all components of the system in the tore) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> l S G Gallons/Day ({Uc�+ `T�..>L I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage.Flow 1 `,� STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> TANK Size: 3 GJ total gallons Pt] single compartment Q <br /> t [] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> rer.Manufactu _ 1n 4.:i _ —itEridc `T tL <br /> Material: l'n Lne.Yr:YZr <br /> [ ] flow-through liel I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer. Header Pipe: The system was installed by: <br /> Size/Mat'I Size/Mat'l [ I Property Owner(pennittee) <br /> L4 Licensed Sewage Disposal.Service - <br /> DRAINFIELD rock depth(inches) Box(es) R17/4r... -7 <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: .3 6n - <br /> Pipe total depth — [ I Distribution [ I Plastic <br /> DEQ Certification Number: ra 7.( . <br /> Drainfield Material(Alternative or perf pipe) <br /> Total Drainfleld Footage — Trench Depth Minimum= Maximum" ._.........-.......... <br /> Curtain Drain Depth_ — Signed: <br /> Effluent Pump: Pump Model — - <br /> Pump cycle <br /> times in minutes: on off -'~ Gallons per Cycle Company name: (3),-- l. a s—lG s-- d- P -c t.-c L. -C <br /> ATT Make and Model — (please print) <br /> Attach an additional sheet for components and materials not listed above. _ Date: CGS — - <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 sys <br /> tem,,,is,:: 1\LAp'pnroved I ]Appro e' ith corrections:see inspectionreport i j Denied <br /> Signed: �'Y► u �Vl ':1 itle: 4 �l`"V.I l/ 1� Date:____� <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:1Fomrs\Septis ' •s-Bui1t2015Version2017.doc �� WHITE:Marion County;YF. LOW.• ner;PINK:Installer <br />