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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> dm <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> ".. .g---- <br /> 503-588-5147 PERMIT NO. Z 3 0 Q GZ <br /> MARION 2 �7 <br /> COUNTY http://www.co.marion.onus/PW/Buildinglnspection tZ 35 / ,��� <br /> SITE ADDRESS: -Cz 1/ ri ie,e <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: / <br /> Scale: 1"= ' rrl b SC.e/i..w <br /> North <br /> i1'• s <br /> , 1/(}j., 140 <br /> eA II <br /> -Nif Li <br /> (f. - 1 <br /> , a..r5 <br /> \ ji . <br /> Ld -f <br /> C C <br /> o,.G ,! <br /> rit Piro, <br /> ep; i <br /> Li,ins <br /> or., ih. <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 /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: -e)13,4-.h., total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ I flow-through I I 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'I Size/Mat'l I I Property Owner(permittee) <br /> -}-Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) p� <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: 3 6/1C7 <br /> Pipe total depth I J Distribution I I Plastic DEQ (j <br /> Certification Number: (, <br /> 73- <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum_ <br /> Curtain Drain Depth_ Signed: <br /> Effluent Pump: Pump Model go . <br /> Pump cycle d P <br /> times in minutes: on off 9014 <br /> Gallons per Cycle Company name:_ p c,,4 ItC„t,e: 3y <br /> (please print) <br /> ATT Make and Model / <br /> Attach an additional sheet for components and materials not listed above. Date:`2LL� 2 3 <br /> (For Marion Cou y Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system ' : 1 Approved I I Approved with corre tions: see inspection report I I Denied <br /> Signed: Title: r � W�'�/ ) ( J Date: �/ <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELL W:Owner;PINK:Installer <br />