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iiimMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. SS'S -2 2 -00is 7 3- pR/r <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: .Zs I Kam,s7 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: - <br /> Scale: 1"=LID ' T <br /> North <br /> µ ou fc_ <br /> e - c : I 7 ' <br /> fJ - C bev a <br /> Li <br /> 4. <br /> !/ - e , [93' I C. <br /> 7 S ' s'. <br /> _________00.,_________A____---- , <br /> ()- 1 s' <br /> (.......A\ <br /> Y' . <br /> show all details and dimensions necessa to locate all corn onents of the s stem in future) _ . <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTE4IN- <br /> System Design Sewage Flow ySO Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN 41C OR- <br /> TANK Size: I I OOO total gallons fir single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: Lro <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: Cunt mid_ [ 1 flow-through 4 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 1 J J y K/ Size/Mat'I 4/ 30 3 I I Property Owner(permittee) <br /> Licensed Sewage Disp <br /> osal Service g P <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe 1A Drop IKI Concrete DEQ License Number: 2 6 -1 q 8 <br /> Pipe total depth I I Distribution I I Plastic DEQ 3� <br /> Certification Number: 8 <br /> Drainfield Material(Alternative or pert.pipe) G L f loL./ <br /> Total Drainfield Footage Trench Depth Minimum ] Maximum_36 <br /> Curtain Drain Depth Signed:_ aitit. (?teaf <br /> Effluent Pump: Pump Model . <br /> Pump cycle p-- // <br /> times in minutes: on off Gallons per Cycle Company name:_ (?c,s 4eil cf,„,...4/11 <br /> / <br /> ATT Make and Model ISt' —2 ree; .j ill ONO 5 td 114-I please print) <br /> Attach an additional sheet for components and materials not listed above. Date: )) <br /> (For Marion Count se Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate Ir <br /> and the system is: Approve I I Approved with corrections: see inspection report I I Denied <br /> Si ned: Title: ak .. 1 ‘0a53.1.4.8 Date: /s <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:AForms\SepticAS-41 As-I3uiIt2015Versiun2017 doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />