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gibli *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 /> MARION 503-588-5147 PERMIT NO. Zi —°c:x ?t a[^COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: (Q 7'�/7 j e.S ' Gb4"4-' <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= T <br /> North <br /> -------"---------------------------"----"-r, <br /> `t .., I <br /> % A 0 1 <br /> � <br /> �-1v 1 1 �S <br /> ,r � <br /> 5 <br /> -.- <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 'y SO Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /o v D total gallons [ ingle compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Olt{Y S [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: CD v`c_ [ ] flow-through I/I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: ri Header Pipe: The system was installed by: <br /> Size/Mafl A/ la ✓ Size/Mat'I 271././303'y I l leroperty Owner(permittee) <br /> tcensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe {— Errop I I Concrete DEQ License Number: a>00 <br /> Pipe total depth I I Distribution { Plastic J DEQ Certification Number: T 21i�7 <br /> Drainfield Material(Alternative or pert.pipe) ec—�S 7 s ' <br /> Total Drainfield Footage I_SG' Trench Depth Minimum'1:I Maximum_21'il <br /> Curtain Drain Depth_ Signed <br /> Effluent Pump: Pump Model C 2f A-W 7005 . <br /> Pump cycle <br /> times in minutes: on Doff Gallons per Cycle - Company name:_ l,.0--L Y t LL S�"%.`C 5 <br /> ATT Make and Model Al 1Lj^ (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: & f I <br /> (For Marion Count se Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system : I Approve l [ ]Approved with corrections: see inspection report [ ]Denied <br /> Signed: Title:, Date: <br /> MC:S-41 rev. ;4/l2;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;11ELLOW.•Owner;PINK:Installer <br />