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r .. <br /> ik1/4 ` 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. 5 j CEO /C, 2�7 eD <br /> MARION <br /> COUNTY` .0 http://www.co.marion.ors/PW/Buildinglnspection <br /> SITE ADDRESS: l S 2) 0 krAird -G <br /> Oil i73 `/'2 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: "= •-.m• T <br /> 1 b t rrs r- . - 5 Nort <br /> �� ' ll o. l <br /> I k <br /> • I 3/ \01° � <br /> 1 C 15 I. <br /> lot IA. <br /> t' ` 4)O / ate' <br /> i 30e <br /> '1 <br /> ,. 3 � r <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 /> System Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1520 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: '741/c(r -�v- <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: <br /> Q`‘.0,j1-: [ ] 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 /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box es <br /> Rock and under pipe I I Drop I I Concrete DEQ Licens Number: <br /> Pipe total depth I Distribution I Plastic <br /> DEQ Certifica .on Number: <br /> Drainfield Material(Alternative or perf.pipe) "_ . ( P-4--,. <br /> Total Drainfield Footage Trench Depth Minimum Ma lynC:.- <br /> Curtain Drain Depth_ Sign v <br /> Effluent Pump: Pump Model . <br /> Pump cycle �1, �p <br /> times in minutes: on off Gallons per Cycle - Company name: -i-Y-vp-e, C1 w ,� <br /> ATT Make and Model ��` itt""" (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: it-) - )7 ,,23 <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: [V4 Approved [ ] Approved with corrections: see inspection report [ ] Denied 1 <br /> Signed: J O itle: 01-w/U/ flm -- Date: f O�Ot+a/ <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-4I As-Built20I 5Version2017.doc WHITE:Marion County;YELLOW:Owner;PINK:Installer <br />