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diaMARION 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 /> + �v <br /> 503-588-5147 PERMIT NO. ` el l Si <br /> D <br /> 1 COUNTY http://www.co.marion.or.us/PW/Buildinglnspection I <br /> SITE ADDRESS: 7967 .35Cd4rewintrl Je::) <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= s <br /> North <br /> APPROVED AS-BUILT p - ,w _ <br /> DRAWING <br /> Li t <br /> CG104- ) G, re-p Iw M <br /> 1 i <br /> I-- C, f PN <br /> 0 <br /> r, - - l <br /> ICf <br /> J <br /> tt N f <br /> r r <br /> t <br /> A. ( N. <br /> I <br /> in <br /> , ` FI' <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 115-o Gallons/Day' STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /SO-CD total gallons /single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: (J./)e,,,14 <br /> [ I double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: Co,-7 e .�_ [ ] 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'l Iu Z7Z9 I I Property Owner(permittee) <br /> [�L icensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) �J <br /> Rock and under pipe 6 r, j4 Drop (Concrete DEQ License Number: 3, <br /> /e...- <br /> Pipe total depth /Z t' I I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) 07Z,/ <br /> Total Drainfield Footage 375 Trench Depth Minimum 2.Z/ Maximum&t., <br /> Curtain Drain Depth LI/A Signed ,.— \ <br /> Effluent Pump: Pump Model WA <br /> Pump cycle 7 <br /> times in minutes: on off Gallons per Cycle Company name:_A - �s3 PL Th <br /> ATT Make and Model /1.� (please print) <br /> Attach an additional sheet for components and materials not listed above. Date:__,/AZ I_ ZZ <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 /> 1 and the system is: taApproved I I Approved with corrections: see inspection report I I Denied <br /> it <br /> Si ned: IL Title: / � S`C% (Q12 Date: 1 'f/2 f Ce I v <br /> MC:S-4 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-BuiIt2015Version2017.doc WIII7E:Marion County; YELLOW:Owner;PINK:Installer <br />