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p� MARION 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. 20— (7O t) to 3( ' <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection 9 &. �//` L. L;J t>0�5 <br /> SITE ADDRESS: <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' T <br /> North <br /> Ste' <br /> 1/ 1 s <br /> J ' <br /> °,. AI?' 00 <br /> r� <br /> y�f' I <br /> SO ' _____\ . <br /> so r b,A <br /> I <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 /> Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: (( total gallons [ ngle compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ���{ [ ] double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: 'L [ ] flow-through A I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: tl Header Pipe: The system was installed by: <br /> Size/Mat'l L) 6,--' ✓ Size/Mat'l I I Property Owner(permittee) <br /> c /j(�p,�Q(� IX Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> rDEQLicense Number: ,374,V19 <br /> Rock and under pipe 12. [ j Drop [ �Concrete <br /> Pipe •I <br /> total depth 11A Distribution I I Plastic <br /> DEQ Certification Number: 1 Z3.1 7 <br /> Drainfield Material(Alternative or pert.pipe) V V <br /> Total Drainfield Footage Trench Depth Minimum 2 LA Maximum <br /> Curtain Drain Depth Signed: 6 �._ <br /> ......,,L......._ <br /> Effluent Pump: Pump Model D . <br /> Pump c me D (1 �f`CS <br /> times in minutes: on off Gallons per Cycle Company name:_ �`'`{ l i �� J <br /> ATT Make and Model A-1C dt R� ICJ�(a O • (please print) <br /> Attach an additional sheet for components and materials not listed abfo`vve.'9 Date: f— 5 ' 1 0 <br /> (For Marion County Use Only) The above septic system has been inspected,}a \vIarion County. The information has been determined to be accurate <br /> and the system is:,ftl.Approved [ ] Approved with corrections:�� see inspection� report [ ] Denied \ <br /> Signed: / RR ( /l� Title:_ail—``VV i 01 t-f'3— 9- Date: C9() <br /> MC:S41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-4I As-Built2015Version2017.doc WHITE:Marion County;YELL W::Own r;PINK:Installer <br />