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gibMARION 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. 5SS- -601 gzi 1 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection S't- <br /> SITE ADDRESS: 7O 3 t <;-i— <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Sc ere ► -I.is *o ltt 9-7 3 S Scale: 1"=iv:i ' <br /> North <br /> t F'x <br /> C i 4,1'Ht <br /> y <br /> i I A7't' 4 D 1 <br /> .2 --- <br /> F <br /> ea wc, F 'ta <br /> 6c - 4Z' <br /> Ali = 85 <br /> R0 - <br /> 15 - Si- <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> — <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> i i I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow —i 50 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I SO�J total gallons single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ! OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Kr double compartment <br /> War' I l ugh (XI I have tested the septic tank and certify it to be watertight. <br /> Material: C!'nitL✓t1� <br /> flow-through <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat't I Wit'ce 1.LW Size/Mat'I `t f7(Jt` I I Property Owner(permittee) <br /> 14 Licensed Sewage Disposal Service <br /> DRAIN FIELD rock depth(inches) Boi(es) � <br /> Rock and under pipe to,' I I�p b4 Concrete DEQ License Number: 3 Oi <br /> 6 <br /> Pipe total depth I Z e. pi Distribution I 1 Plastic DEQ Certification Number <br /> Draintield Material(Alternative or pert'.pipe) PGv-f <br /> Total Drain6eid Footage )96 Trench Depth Minimum It. Maximum, !74' <br /> Curtain Drain Depth_ CAr1t.`'s Pt II Signed:_ 7,/,7 :4";-------/---2' <br /> Effluent Pump: Pump Model C)vtyt[[) Pr . <br /> Pump cycle Pe, <br /> times in minutes: on — off -- Gallons pa Cycle +'14-t—c-.+2—..r- Company name: (3ifyeoa s z - - Ot K 1 L <br /> ��{ aa >l-C c A X,.�t3 )7 I () 3 (please print) <br /> ATT Make and Model Ad tic,vs. �J �3 -y <br /> Attach an additional sheet for components and materials not listed above. Date: -( - -i_ -/ <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 ed with corrections:'see inspection report I I Denied <br /> Signed: 0/ 11 itie: —Wit)It)/4 ( fCYD Date: I i ac <br /> ;5/14;11/17 G:\Forms�tic1S-41 As-Built2015Version2017.doc WHITE:Marion County:YfbL :Owner:PINK:installer <br /> MC:S 41 rev:3/03;4/12 ep <br />