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I1 <br /> MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM5 3-588 OR 97305 PERMIT NO. 55S - Z Z — 00 %m l`/o <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection CXsa ,4� <br /> SITE ADDRESS: Sy DEZZJ uN Rgt SC <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1" = 1' <br /> North <br /> -1, .;) ( YiliS@ r <br /> •, <br /> . , <br /> , _ , <br /> ...4 . AA>, 0 <br /> • K. <br /> 1:I v,, ..:. ,a_'1'' Scla I,, <br /> t '9 . <br /> �; wrzt <br /> . <br /> A 'PILAU WA �` • . , <br /> s - 6 /S AO I <br /> �o <br /> poi � q od <br /> A-6 I&®• ® � al <br /> ® ' `\ � A-C �ifa i ®\ � \ , :, ...--- .0y-- ► • <br /> o A-- D c <br /> rI ' A <br /> I <br /> 6 6 <br /> • � s71-4E AaA A~ � <br /> fq)A((� 7 9 <br /> 1, <br /> `- gmtAi I <br /> (show all details and dimensions necessary'to locafe aT1 cdmponents of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> l� Gallons/Da I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow y STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /000 total gallons 4 single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> PA [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: COg)C./ar [ ] flow-through ])0I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: had Pipe: �t The system was installed by: <br /> Size/Nat'l pixie_ <br /> Sizee/Naert'l 3 pin. <br /> e. 0 I I Property Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe (Q.' 'Ki Drop Concrete DEQ License Number: is 25.7 <br /> Pipe total depth f Z I I I I Distribution I i Plastic 1" �� /_ Z 3 <br /> � ��. DEQ Certification Number: lJ <br /> Drainfield Material(Alternative or perf.pipe) � 14 r 4 p4 P <br /> Total Drainfield Footage #30V I Trench Depth Minimum VelMarimum10 e <br /> Curtain Drain Depth Signed: <br /> Effluent Pump: Pump Model . <br /> Pump cycle ,44 <br /> times innminutes: on off Gallons per Cycle Company name:_ <br /> ATT Make and Model (pease print) <br /> Attach an additional sheet for components and materials not listed above. Date:---67-60---21 <br /> (For Marion Coun y 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:.]t`4Approved I ] Approved with corrections: see inspection report I I Denied <br /> Signed:_ Title: 614--A) IQ 14-4B"q t9- Date: <br /> MC:S-41 rev:3/03;4/12;5/14; 1 /17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County: YE LOI :Owner;PINK:Installer <br />