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'iiki. ` 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. cS.S S -- Z I — 007 7-S k1 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection �VOr� ��..►1L 1.+ <br /> SITE ADDRESS: -Z�'(Q� '�� >`p <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> rr`-ale' t n= ' f$ f��rw r�.OM ` • <br /> • , y / _ - 'I` <br /> Pro <br /> 1 <br /> a fa 1IV / 1 r f Mort North <br /> scale: 1 = 1, _ n T.!:Vs3� 4 <br /> C// \I _ <br /> S <br /> fa It, <br /> `''`� Lief <br /> ,� t '- ,� 1`S 1s <br /> (,V ti,2/t I?040f SYO Se 1'rv11 <br /> \ , <br /> 10 it, c /Do, <br /> la 71-. E = as keo c"..4..,ek. eavas <br /> 0 i`Ce CC3 ~'-" 1°211 •7)I a..- <br /> ohio ~_ if 0 k ` — <br /> Ltit IV C Z.: i EXPIRLL' j• <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: total gallons [ I single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> [ ] double compartment <br /> Manufacturer: <br /> Material: [ I flow-through I 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'I Size/Mat'I I I Property Owner(permittee) <br /> Ixi Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe pirDrop I I Concrete DEQ License Number: 3 7 <br /> Pipe total depth I I Distribution iXPlastic DEQ Certification Number: 1_22 5 7 <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum i\ <br /> Curtain Drain Depth n Signed:_ V '.. . <br /> Effluent Pump: Pump Model i� !/ p vt.„fL- 1 <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle - I <br /> Company name:_Lit�-� r• `: �,. �tl., t C S <br /> (please print) <br /> All'Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: <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: [ ] Approved [ ] Approved with corrections:see inspection report [ I Denied <br /> Signed: Title: Date: <br /> MC:S41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built20l5Version20l7.doc WHITE:Marion County; YELLOW:Owner:PINK.Insialler <br />