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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> iiili <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> + <br /> 503-588-5147 PERMIT NO. -lV 0045(O <br /> • MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection C �1 S r <br /> �3 <br /> SITE ADDRESS: Z�Ipq <Y'C\ V�2.1' �n. <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale= ' ts&T ID 5 ite 1 - "' - <br /> 1 ‘-� j North <br /> //\, <br /> \ zY• rt)—(? l <br /> 1' 11 <br /> �.�� g -(.,1 «.4 <br /> 1 <br /> - ,. .g\ 'Q `o1. `C� c - 6 ;I1 <br />, -) 1/4..A\ - \ • '• _A-le, 0 - C ----lair <br /> `N <br /> ` _ <br /> ,. _1 J <br /> /, Q - — 6Zi tt <br /> ` ZI <br /> c _ <br /> AflaWcOY 41k) fil-t- a-(- <br /> 5--ATT <br /> �--e=p !� -I — <br /> . Nt)(A. <br /> 4 1 -3 - it;s <br /> (show all details and dimensions necessary to locate all components o the system in the future) J -Kr-a <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> y DesignSewage �� Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 15 00 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> L ouble compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: ��‘C�'/ <br /> Material: C pV\LV bkIz [ ] flow-through I I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: / Header Pipe: 1 I S The system was installed by: <br /> Size/Mat'1 \'1 . Nib Size/Mat'I 4 3O3-\ I I Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service • <br /> DRAINFIELD rock depth inches) Box(es) <br /> Rock and under pipe IV Drop ] oncrete DEQ License Number: 33 g 3`� <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification umber: I ' <br /> Drainfield Material(Alternative or perf.pipe) £2 v.(O <br /> .•. <br /> Total Drainfield Footage 4� Trench Depth Minimum Maximum 3i <br /> Curtain Drain Depth_ t� _ Signed:_ <br /> Effluent Pump: Pump Model 1'n{ �D V( � <br /> Pump cycle + <br /> times in minutes: on off Gallons per Cycle Company name:_ C e \ Ci0 AScc j .YI`011 Y►\.C. <br /> ATT Make and Model IA „ J) (please print) <br /> Attach an additional sheet for components and materials not listed above. ' _;"'` '.';d= Date: `p — 12 - <br /> (For Marion County Use Only) The above septic system has been inspected'by Maron;'County. The information has been determined to be accurate <br /> and the system is: [Approved I I Approved with corrections: see inspection report I I Denied <br /> Signed: ______� Title: P' H l 62,2 q ( <br /> Date: l l t l <br /> MC:S-41 rev:3/03;4/12;5/14'; 11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />