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h� MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 1 �""�`-`� 5155 Silverton Rd NE (to be completed by system installer) <br /> 503E 88- 14 97305 PERMIT NO. Sjfs- /- o d q 7 7 lV <br /> COUNTY -77�� //1�r Qh //�� <br /> http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: / U ' rI D4V-G t A <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Dif T 7 3 V 2 <br /> Scale: "= ' _ l � T <br /> 16i frd Pe ki , s Nort'1 <br /> r � <br /> I 12 it S <br /> 2-b � � r <br /> o r <br /> I \ J <br /> \ CP' ‘ <br /> 3$ <br /> 31 � <br /> 4 <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: I.5)6 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: ',,vc(i 4—teem Q'V� [ ] double compartment <br /> Material: pl e,,,` [ ] 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'l 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 ( 1 Drop [ J Concrete DEQ Licens Number: <br /> Pipe total depth 1 Distribution 1 Plastic <br /> DEQ Certifica 'on Number: <br /> Drainfield Material(Alternative or perf.pipe) frec4r-.2.- <br /> Total Drainfield Footage Trench Depth Minimum MaiLLAG- <br /> Curtain Drain Depth_ Sign <br /> Effluent Pump: PumpModel <br /> Pump cycle <br /> times in minutes: on off Gallonsper Cycle Y Company name:_ /.-ei CJ �— <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 10 — )7 r O.3 <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: [ J Approved/ [ ] Approved with corrections:c/ see inspection report [ I Denied , / <br /> Signed: Ib/� aL'IWV AX/tI'itle: 6N w/D I q l U g— Date:____( /ole <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW.:Owner;PINK:Installer <br />