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iti _ MARION 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 /> 503-588-5147 PERMIT NO. 21 - 007,311 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection // I/ <br /> SITE ADDRESS: 1 0 N76 �I7/f ys��C Co <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> scat 1"=3G ' -4. T <br /> r�.� EXPLRED <br /> North <br /> ! 1 <br /> i .. <br /> -..._ <br /> „ ,..,....„. <br /> d = <br /> . <br /> (--)_0:y. ' <br /> "� <br /> H <br /> Q <br /> y <br /> s z• <br /> t it <br /> y'- I 1 <br /> Cl �4, c d <br /> (show all details and dimensions nec•ssary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> b I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow D Gallons/Da y STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: iIpoo total gallons bc] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: v.:4 y <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: hp-pc [ I flow-through IA 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 /> kJ Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) 3 /b' g <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth I I Distribution I I Plastic <br /> DEQ Certification Number: 6 3s <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage Trench Depth Minimum Maximum � � <br /> Curtain Drain Depth Signed:_ ,a.€1., <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ (3,e41.61 6AL <br /> ATI'Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: Ii /id <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 I Approved I I Approved with corrections:see inspection report I I Denied <br /> Signed:_ Title: Date: <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />