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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> gibi5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer)503-588-5147 PERMIT NO. 2i U J 0 '' 0 3 51 2- <br /> MARION �� `� <br /> COUNTY htt //www.co.marion.or.us/PW/Buildin Ins ection z 1 3 <br /> P� g p SITE ADDRESS: 3 N 6�`-c� cei ( <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= 40' T <br /> l North <br /> 1v <br /> 't l <br /> 1 <br /> ZO <br /> N) <br /> G —, <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 /> �,r' I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow LIJ v Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /000 total gallons I ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: (�� f 4-c'5 W double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: C6KJG [ I flow-through 24 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'l Size/Mat'l I I Property Owner(permittee) <br /> of Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) I <br /> 'ock and under pipe b I I Drop I I Concrete DEQ License Number: (�� t <br /> Pipe " <br /> total depth 12I I Distribution I I Plastic DEQ Certification Number: j... 1 <br /> Drainfield Material(Alternative or perf.pipe)Total Drainfield Footage 5bO 5FTrench Depth Minimum/9Maximum. () IAmm <br /> Curtain Drain Depth_ er" Signed:_ `0 r li <br /> Effluent Pump: Pump Model 7 —3 0 . <br /> Pump cycle ,) L 3 <br /> 1 �G cyc, <br /> times innminutes: on 3 V off 40 Gallons per Cycle J Company name:_ I{-°,x <br /> (please print) <br /> ATT Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: / 2. <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: Approved I I Approved with corlreecctions: see inspection report I I Denied <br /> Signed: - Title: �`/ > C Z7 f Date: k` VriV <br /> - <br /> MC:S-41 rev:3/03;4/12;5/14;11/1.7 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />