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�w MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> _� 5155 Silverton Rd NE (to be completed by system� installer) <br /> — —. 5 3-88 SALEM OR 97305 PERMIT NO. S—Sr )J- J� <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection Q ' ,I,, n � �Q <br /> SITE ADDRESS: ��� '•�Vi��"�,, F--('i�S <br /> - 3-4-k <br /> • <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 1 <br /> Scale: 1"=_' T <br /> North <br /> ei <br /> d <br /> e., . <br /> • <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 /> System Design Sewage Flow %'(60 Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANKSize: l�aP , total gallons ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> ��Y/ [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: ,c jf� [ ] flow-through I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer?,`,p „l( t( Header Pipe: T-h ystem was installed by: <br /> Size/Mat'l V Li .,Gri • TD -7 Size/Mat'l Property Owner(permittee) <br /> 1 Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe Der Drop VI Concrete DEQ License Number: <br /> Pipe total depth I I Di l uti n I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) , <br /> 'a <br /> Total Drainfield Footage AW,OTrench Depth inimum• y Maximumjv J <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model <br /> Pump cycle &- YY` <br /> times in minutes: on off Gallons per Cycle Company name:_ elmilt ATI'Make and Model (pl8ase print) <br /> I <br /> Attach an additional sheet for components and materials not listed above. Date: V 1 /g--5 <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; 'S.]Approved [ ] Appr i v d with corrections: see inspection report [ ] Denied <br /> Signed: V\ ' Q't i e: / -1A 10) 1 89 Date: qi /MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20l5Version2017.doc WHITE:Marion County;YW:Owner;PINK:Installer <br />