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AmMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer)503-588-5147 PERMIT NO. c c S_- 2 2 — Q Q 7 f 6 6 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Build Ins ection t. AA <br /> p� g p SITE ADDRESS: ���Q (j � pi, iv I f dlrnv, <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ j <br /> 2.00` TG vVe u T <br /> -? North <br /> Iaf Ib, 10 10 20'___, <br /> Q( 2ii \ <br /> I <br /> A✓Cd , <br /> S(,,r,e. ; fyt�n n>, <br /> .c--- <br /> 2elzf;;rc Ek,tzF.opi/ ►., I <br /> • ' <br /> ✓ iu�n-t�1� l+2:�k.h 1 <br /> 1 <br /> Tzel k - Z a qd, <br /> 8'x 1 - 3 <br /> 2. — 3q <br /> Id iod <br /> if S " 1 <br /> S34 <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 /> 1 HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow N G Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /.cod total gallons [ersingie compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> �� Grys{ [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: , dnnt <br /> Material: C_Y1C [ ] flow-through V 1 have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: ,.1 Header Pipe: ,� The system was installed by: <br /> Size/Mat'l V 3 0-7 y rlil�GSize/Mat'l y 3 6,-;y iI Property Owner(permittee) <br /> 1 icensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe Itop ICI-Concrete DEQ License Number:,Ji�2-_r <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: / D <br /> Drainfield Material(Altemative or pelf.pipe) C 2.. --,/r Irizt/ // <br /> Total Drainfield Footage 3 ea' Trench Depth Minimum y"' Maximum36" �� <br /> Curtain Drain Depth Signed:il,L <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:6 tirf au t, i 7y t <br /> ATT Make and Model (pleaseKM) <br /> Attach an additional sheet for components and materials not listed above. Date: P-k"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: [1]Approved [ [ Ap with corrections: see inspection report [ I Denied <br /> xvoluSigned: r► cflhci Date: , 119 /2? <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic '-41 As-Built2015Version20I7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />