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I <br /> iimMARION 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. 2 2 - 010 4-44 l'i4n'- <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection 8 S (c- Sn.-.) L. <br /> SITE ADDRESS: 4"C7 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' ' T <br /> '''\ou e North <br /> A - c - '2y'. ",� (. »tie D _ 651 <br /> B - L 2 S 1 1.:oe E 106' <br /> G — nz SZ� I L14e, F = (IS' <br /> I) - K = f 2 - L,,oe G = 125' <br /> £ - F 3 . S' oz .' C[e.✓t c L;vie H - 4S <br /> F =tglz i a . 5' Deal <br /> GI= u : 1 1 ' _4"DWV <br /> A� 4s <br /> 0 t;tf''0 5'4 Conct the µ <br /> C. <br /> O <br /> 1 p G5 F <br /> ' � ios <br /> concre p(� 1-704*N. IS ' <br /> r GI �2S ` <br /> N q-" 30 - <br /> w <br /> 1 4" OW" 9 r Q <br /> .-_,...0 14 <br /> c 4S l <br /> (show all details an ns necessary'to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> y DesignSewage2.2-S Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System FlowSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1000 total gallons D4 single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> i ( �� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: C.On•CIl c--IC [ 1 flow-through p41 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 till wJV Size/Mat'l I I Property Owner(permittee) <br /> lr Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe DEQLicense Number: <br /> p'p � Drop Concrete = Z. <br /> Pipe total depth 12." I I Distribution I I Plastic <br /> — DEQ Certification Number: <br /> Drainfield Material(Alternative or peril pipe) <br /> Total Drainfield Footage di SO. Trench Depth MinimumL.ga Maximum_2 in <br /> Curtain Drain Depth Signed: <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: Q Vn/s. C 0"A 4-f v c--44.0 r. <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: l0(/IA 123 <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: fQpproved I I Approved with corrections: see inspection report I I Denied <br /> Signed: Title: IZC' "( ty 21( Date: 121? 2 l v2 <br /> L MC:S-41 rev:3/03;4/12;5/14; 11/17 G:AForms\SepticAS-41 As-Built2015Version2017 doc WHITE:Marton County; YELLOW:Owner;PINK:lnstaller <br />