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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 <br /> 503-588-5147 PERMIT NO. 2,2-007 Z Z.. <br /> MARION <br /> COUNTY i l <br /> http://www.co.marion.or.us/PW/Buildingnspecton r <br /> i SITE ADDRESS: �c�l� ��'����"�� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ T <br /> North <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_ 450 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: WOO total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: � 4Z G/'c,{-t <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: Corse-re-4 Z [ ] flow-through 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 Le DU-)0 Size/Mat'I I-t't 3 C' - } 1 Property Owner(permittee) <br /> 'Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe .56 Drop I I Concrete DEQ License Number: <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: r Z-5 1. <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage I aD r Trench Depth Minimum -''t" Maximum 'SO y <br /> Curtain Drain Depth Signed:_ <br /> Effluent Pump: Pump Model R17-30 <br /> Pump cycle �+ <br /> times in minutes: on off Gallons per Cycle ati Company name:_ des C ov- 4rc,c_4-:U,r,. <br />• (please print) <br /> ATT Make and Model A-g 2o lZ I /> <br /> Attach an additional sheet for components and materials not listed above. Date: �e 2-c) /23 <br /> (For Marion Coun y 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: —ApprovedI I Approved with corrections: see inspection report ( 1 Denied <br /> Signe Title: KF J I7- l on S Date: / / <br /> MC:S- v:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />