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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. 55- e'— Z Z-- al o f e q - 1°/j j-c ) <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection J <br /> SITE ADDRESS: 1 3Q39 erh rLohel'I- $ °� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= 6151'il <br /> T <br /> ?Oct}, North <br /> A'1 ' •5' i <br /> l$0 ' © ' co' <br /> re R r- ps re w C` • <br /> 0v1tllyn5 6. n Ell eA'i5t`''"f <br /> 3 <br /> l <br /> 0 - fit;si "S Na <br /> N 5 '1 a <br /> 4t,i <br /> I� <br /> IT-egad" . <br /> . <br /> P — 80� % t?' <br /> t <br /> i <br /> 0- p poi.. 1O1 <br /> �p i <br /> U® a f-reel (r'fti 4 y 11,4-G- I) <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 /> y DesignSewage9SO •Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 10G0 total gallons [ single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> y,/ri� �-� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: Co. CMG le.- [ ] flow-through I,6have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: It pp. Header Pipe: II The system was installed by: <br /> Size/Mat'I t{ rig...) Size/Mat'l t{ 1 v L I I P operty Owner(permittee) <br /> [ Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth inches) Box(es) 9O ir Cj <br /> Rock and under pipe G I I Drop I oncrete DEQ License Number: <br /> Pipe total depth 1 Z kI'Distribution I I Plastic <br /> - DEQ Certification Number: PI 9 09 <br /> Drainfield Material(Alternative or perf,pipe) tt it <br /> Total Drainfield Footage 161 <br /> I Trench Depth Minimum I Z Maximum I ( <br /> Curtain Drain Depth Signed: h'L/ <br /> Effluent Pump: Pump Model 1 F 3oo C <br /> Pump cycle C <br /> times in minutes: on off Gallonsll per Cycle Company name:_ A-Kb 1- GGn sfirC a t14- ,- l <br /> ATT Make and Model Orin CO la h.TIV (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 8') lilts <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: [ i Approved i i Approved with corrections: see inspection report I I Denied <br /> Signed: d` itle: �itH-5� to 33 g" Date: Z- iok-Z3 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-4I As-Built20l5Version20l7.doc WHITE:Marion County; YELLOW:Oivner;PINK.:Installer <br />