Laserfiche WebLink
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&.' .22 <br /> MARION _ <br /> COUNTY �J ��http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: ® 4I . ,,,,a, i a). ME- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: `Lri r"I <br /> Scale: 1"_ T <br /> North <br /> lt4 _ <br /> pik <br /> /0411-61.11./. <br /> til <br /> ( N $-rkli <br /> _ .. <br /> ./611 wip3'r <br /> \\ 2/o <br /> \ 1- „ <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: /56° total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer:? <br /> t:. W�1(-!� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: o.J ,2.. X flow-through V.Lhave tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: ( "l 7��)� �f Header Pipe: The system was installed by: <br /> Size/Mat'I D f tL-Size/Mat'! i J Property Owner(permittee) <br /> [)(I Licensed Sewage Disposal Service <br /> DRAINFIELD rock de t 'He}res) Box(es)Rock and unde ' I 1 Drop I Concrete DEQ License Number: 56 /7 V /�j <br /> Pipe total depth I istribution I I Plastic R- I S—� • <br /> 4. DEQ Certification Number: <br /> Drainfield Material(Alternative or pert.pipe) <br /> Total Drainfield Footage mimum Maximum r— c <br /> Curta' n epth Sign 6: . <br /> Effluent Pump: Pump Model Li&JIM-1 eat?) <br /> Pump cycle 'J 4/ <br /> Q times in minutes: on a" off Gallons per Cycle I C '7r Company name: -Z'I�,f"lam -xC-4V4t elb, /We <br /> ATT Make and Model -5 /( ease print) F✓ <br /> Attach an additional sheet for components and materials not listed above. Date: 5/2- 02-- <br /> (For Marion Count 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: �b Approved I ppro ed with corrections: see inspection report I I Denied �( ? <br /> Signed: '?uvuW LL a • itle: E - W i n- �2 Date: 'I I a�(J di <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Fo ms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County; YEL OW.:Oivner;PINK:Installer <br />