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gibMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 /] <br /> 503-588-5147 PERMIT NO. -d'1—'00S-33! <br /> MARION .. :. _ . <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection �93 PO:f lJ U SITE ADDRESS:AS-BUILT PLAN OF.CONSTRUCTED SYSTEM: \ ` cl, 60`�/ <br /> e5' <br /> Scale:1".. • a - 9 is <br /> . <br /> • \. North <br /> �B r7i. <br /> • <br /> 19.•• 0. <br /> • <br /> • <br /> (show all details and dimensions •tecessary to locate all components.of the s}stem in:the future) •` <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION:: . <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- . <br /> System Design Sewagewa plow Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> 'TANKSize: wrG�� . /`'total gallons [ ].single compartment DANCE WITH THE REQUIREMENTS OF.THE PERMIT AND THE RULES <br /> Manufacturer. 'l t/�, i''Sy' . '-' •.. double compartmen OF MENTACOMMISSION. <br /> T <br /> v [ ] flow-throe h ` •' .t ,1/p I THE <br /> e:septic certify itto be watertight.ENVIRON QUALITYION. <br /> ve•tested t} tank andat <br /> Material: {,C�'r7t7f�'y�- �. . . <br /> Effluent Sewer:.p i C,, I Header Pipe: The system was installed by: : : <br /> Size/Mat'l 'I /4 •n 1(�1)0—Size/Mat'I _ • 1 ]Property Owner(permittee) ' ' <br /> ,[i11 icensed Sewage Disposal Service . <br /> DRAINFIELD rock depptth(4tehes), Box(es) <br /> Rock and. under pipe `�y +, rt' l ]Drop I I Concrete DEQ License Number ck.3J�. <br /> p 4. <br /> Pie; total depth 4,1 16I 1 l Distribution .I Plastic .--1. i�7 <br /> DEQ\certification Number: `/ +�! :/ <br /> Drainfield Material(Alternative or pert pipe) Loy. Piie eei'c, <br /> Total Drainfield Footage 4'/ Trench Depth Minimum/ Maximum (' <br /> Curtain Drain Depth fO Signed: ' <br /> . Effluent Pump: Pump Model p_ ( <br /> Pump cycle ,. <br /> times in minutes: on' off Gallons per Cycle Company name: f�/E.�_, (�C' tC , <br /> ATI'Make and Model 1/0 , <br /> (please print) . <br /> • <br /> Attach an additional sheet for components and materials not listed above. Date:_ <br /> For Marion Use Only) The above se ' system has been.in inspected b y Marion Count The info matio has been determined to be accurate <br /> ( County Y Sp Y Y n <br /> and the systems: p Approved ' I oved with corre tions:see inspection report 1 1 Denied <br /> ��`� ' .. : <br /> • Il n <br /> Signed: r .I I. ,�aI. , . , /��� Fttle.' d I��`7 / d Date: i . <br /> MC S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\,Septic\S-41 As-Built20l5Version2017.doc 1 WHITE:Marion County;Y LO :Owner,:PINK:Installer ':. <br />