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gibiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 . . • PERMIT NO. I S-O ,14- Puri <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection (a 2 5vJCz voc t <br /> SITE ADDRESS: !/�e_ �.s. � <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: `�,, I Of... G�3 11 <br /> Scale: 1"_NO' Pro pot L, Li(lc. North <br /> it P•4 <br /> Rt t _ ;1e,S 1Di-Pro n Qro .e.v I✓k IA e, 4 <br /> II <br /> ;C ti• A' d\` N k . <br /> �° fsP sa ` �r r�, <br /> `, t -0 <br /> d` <br /> J. 4® i ` G <br /> (r,' < E-!" - 4R Imo► �"° <br /> / <br /> n { �'4 <br /> / <br /> _I LIYl2� p III <br /> 3"I S �D s <br />' . ---/ % <br /> 7 . . . <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> 1 SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I °C) total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ut�Q double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: i0 <br /> Material: COtICreke, [ ] 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/Mat'I Size/Mat'l V Property Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe (Pt` I I Drop 'hc]Concrete DEQ License Number: <br /> Pipe total depth I2. XDistribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) " --c file, ,, <br /> Total Drainfield Footage 45 Trench Depth Minimum it Maximum 7> � ( <br /> Curtain Drain Depth Signed: '"'"S'O <br /> Effluent Pump: Pump Model Oa-MO 1Pg3 0061\ <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: <br /> ATT Make and Model (pleas print) <br /> Attach an additional sheet for components and materials not listed above. Date:_ C4\2S�7- ' <br /> (For Marion Co my se Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the syst m is:approved I I Appro ed with corrections: see inspection report [ � Denied <br /> Signed: a-ttiatitr0.4-wtoiLilioia_ Date: d 2,q <br /> MC:S-41 rev:.3/03;4/12;5/14;11/17 G:\Forms\Septic\S-, As-Built2015Version2017.doc WHITE:Marion County: YEL OW:Ow er;PINK:Installer <br />