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hS MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> I SALEM OR 97305 <br /> 503-588-5147 . PERMIT NO. - -5-27-0U cc 17- PRAT <br /> MARION �^COUNTY http://www.co.marion.or.us/PW/BuildingInspection s ' n G S.E, <br />� SITE ADDRESS: i tl �Ct'G�1-f�r di 4+ �i . <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: �4 'G� G ' <br /> Scale: 1"= L[U'' North <br /> --C, � s1t y�«y� <br /> Q—L <br /> a- p = 10' Nwsc <br /> IV <br /> i' S's • <br /> ,--.----' 9 og" <br /> (j L Ir1 <br /> ill <br /> /j .\___,..::„..,,,, ,,.-- <br /> , <br /> U • <br /> I <br /> I. <br /> 20 <br /> N _ -`I__ <br /> h. <br /> �° , \\S \of) ,i <br /> (show a etails and dimensions necessary to locate all components of the system in the ftpture) �‘J EA <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: • <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow I-156 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1, Irl(70 total gallons pc single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ` OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: Vie. �t [ 1 double compartment <br /> Material: (Lott [ ] flow-through I)G 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 G'' Size/Mat'l Lit I I Property Owner(permittee) <br /> IA.LicensedSewage Disposal Service <br /> DRAINFIELD I rock depth(inches) I Box(es) I Rock and under pipe (].Drop jRI Concrete DEQ License Number: 3 61�7C <br /> 8 <br /> Pipe total depth l 1 Distribution 1 1 Plastic g's <br /> /� DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) C z-+-lu.... <br /> Total Drainfield Footage Ciro Trench Depth Minimum 7 t/ Maximum_2 6 (� � � <br /> I ��J <br /> Curtain Drain Depth iv/1*. c -K�- <br /> Signed:_ t. <br /> Effluent Pump: Pump Model 4i0 . • <br /> Pump cycle _ <br /> times in minutes: on off Gallons per Cycle Company name:_ �5 f7&AG( CG redo si-)S <br /> �/4- (please print) <br /> ATT Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: ]0 16/71 . . ____-__:-;--- <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~ k1I12 <br /> �]Approved [ roved with�correcstiioons::seeee iinnssppection report [ ]DeniedSigned:i1 et C0Q, itle: *V IUI(-1 I V l,�'�-- Date: /01b 57 <br /> MC:S-41 rev:3/03;4/12;5/14;1 1/17 G:\Forms\ eptic\S-4I As-Built20 15Version20 1 7.doc WHITE:Marion County;YELI;OW!Oarn'er;PINK.Instaler <br />