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• MAilI0N COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> DIVISION (to be completed by system installer) <br /> oe"to" 335 Court St NE)PO Box 14500 `^ <br /> COUNTY- Sdat0OR97309-SDM 1 1 W - 1 �rte /2e�s <br /> (303)5884141 SITE ADDRESS: (firr-- �.(�+� �•.!�- C �.�J <br /> PERMIT NO. Qlo — O3 (SQ <br /> AS-BUILT PLAN OFCONSTRUCTED SYSTEM: <br /> scale: 1" tag 7 S'uurPINId,S A • t <br /> ( : N+ E ' i / North <br /> r ... <br /> O AfJ / <br /> A - E - 1z` ,. ,rya, <br /> 0 <br /> A -D r 43 ,c. wail- <br /> ,6[I C oA,,s <br /> 13:'." C3 :: 25 6 --i <br /> -dc. A <br /> ec <br /> )- C.- = ay, 3 " -rhhk . <br /> • <br /> b-p - 5g privec.v <br /> Q -- F = Lb, 6 ]' • <br /> ! -D = 52' <br /> (show'aall~l - etails�anu imensions necessary to locate all components of the system in the future) <br /> a <br /> ' SYSTEM )ATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION, <br /> System Design Sewags,p ` <br /> lov, Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br /> ex S T �n,, SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br /> ' Septic Tank: 'Size: Ma /Ckao 9'� Mfg: STRULTEU IN ACCORDANCE WITH THE REQUIREMENTS OF <br /> /� A1 �1 ♦A�r THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br /> Dosing Tank: Size: �]OQtCQJMat'l: Conuu^l Mfg: ,A,t,S Q ALITY COMMISSION. <br /> c JJ I have tested the septic-tank and certify <br /> Effluent Sewer, Size: "di Nat'l: AST M , (9(9 Os % it to be watertight. <br /> Box(ss): }('-1 Distribution; [ ] Drop / ( 1 Concrete; ( ] Marc The system was installed by: <br /> �ar e�U..j ( 1 Property Owner (permitee) <br /> Drainfield Pipet Size, Material: Header:ri /i rf:�5-q I Qt), Licensed Sewage Disposal Service <br /> ' �{ ' 1 Q� <br /> Total Dzaiafisld Footage: ��; Rock Depth, Total: ��K Under pipe: �M DfiQ License Number: 3 ! S <br /> Alternative Draimtisld Materials: f • �3, <br /> ''JJ <br /> Trench Depth: Minimum:\L�,.1—{u; Maximum: a4,), Curtain Drain Depth: /f4A Signed: n ,�- n ,.L <br /> Effluent Pump: Pump MoNliar° S(goStatic Head in System: !7 Ft. Company name: lea. Se_ 1 8 c.krt o , <br /> ff Ken (please print) <br /> Pump Cycle Time: Ke 1 ; Gallons per Cycle:9 C)f'�j . /l l2 8 1 0(o <br /> (fh Date: !I! 4 CJ IQ • <br /> Attach an additional sheet for components and materials not listed above. <br /> (for Marion County use only) <br /> The ve septic system has been inspected by Marion County. The information has been determined to be accurate and i <br /> th ystem is: <br /> Approved <br /> [ ), Approved with corrections: see inspection report <br /> [ 1' Denied <br /> Signed Title: rA Date: 9444. <br /> MC: S-41 WHITE:Marion County; YELLOW:Owner; PINK:Installer <br /> rev: 8/00,6/01 <br />