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"�` 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 503-588-5147 PERMIT NO. C 55—Si `Of I q 91, �1'�/� <br /> ?A T <br /> MARION <br /> COUNTY ti l ildi/PW/B i http://www.co.maron.or.usungnspecon <br /> i C��rSITE ADDRESS: ��$�7 1.�;o•>t-i�re.rc c.IC ea. �� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> • <br /> Scale: 1"= f® - T <br /> llra 4- -1-0North <br /> 151 -I <br /> • <br /> �—�= 1 �8' �13 _ <br /> i -Q� las' 4 * ' <br /> 14 - c = IS'61 -)QLI <br /> $ — E; 165 e <br /> b� <br /> nc <br /> 1 e p <br /> / <br /> ,,,--"-- <br /> -0 'a, > r. <br /> -II, I <br /> v <br /> 10e (vC <br /> �� _. I 90 g9r0 _4 <br /> I <br /> L4.. •/G. WAN`\tj1' 6G•661 <br /> (show all details and dimension necessary to locate all compone is of the sys(em 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 I-Lco Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I, 000 total gallons [X.single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> 1 Manufacturer: i../a"�tl [ ] double compartment• OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: C oncre4a— I I flow-through 1)(4 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pi e: The system was installed by: <br /> Size/Mat'I I�/h Ove- 0fejJ u . Size/Mat'l pLl't?io3'J I 1 Property Owner(permittee) <br /> [AI Licensed Sewage Disposal Service <br /> DRAINFIELD I rock depth(inches) Box(es) <br /> Rock and under pipe 6 l)¢.Drop Concrete DEQ License Number: 61 g 8 <br /> Pipe 1r <br /> total depth IZ I I Distribution I I Plastic <br /> DEQ Certification Number: e 3s <br /> Drainfield Material(Altemative or perf.pipe) <br /> Total Drainfield Footage I.0 Trench Depth Minimum I B Maximum Vi <br /> Curtain Drain Depth t-I2" Signed: o1.c.Q-- Peo/ e../ <br /> Effluent Pump: Pump Model . <br /> Pump cycle ' /1 �^Y- <br /> times in minutes..fr -- off Gallons per Cycle Company name: 1.9/�4l c. C`I cil®-A4e)7o, <br /> J pp S wrrN er iA.' cr6ri `r(please print) <br /> i ATT Make and ModelAZo sT'=1 g12, e.,R.13 o 25 b— <br /> Attach an additional sheet for components and materials not listed above. CJ Date: 7/ 2_/7,Z <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 corrections: see inspection report [ I Denied <br /> ��pp ' <br /> Signed �� Title: V'\-,,, ►>trS `627 Date: <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built20l5Version2017.doc WHITE:Marion County; YELLOW.:Owner;PINK.:Installer <br />