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gib -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. 2/ -OCt, ?if-O <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: (Q. 7`-/7 j e ss A- L,-'l^'(y <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= T <br /> North <br /> i .....„,._ <br /> no <br /> I, ' <br /> i Are 42.- <br /> I i <br /> 1 S� <br /> `it" <br /> / <br /> m ;. <br /> 15 <br /> 5 <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 `i.54.7 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /0 047 total gallons [4ingle compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: e.a_)61s}•G S [ ] double compartment OF <br /> FTTHE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: CD.......A.._ [ 1 flow-through I/I 1 have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: i Header Pipe: The system was installed by: <br /> Size/Mat'i '/ l ✓ Size/Mar l 271 f /.3034I I I Property Owner(permittee) <br /> tcensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe eilllop l I Concrete DEQ License Number: a7(7/ <br /> Pipe total depth I I Distribution {Mastic <br /> �, DEQ Certification Number: T 2jf <br /> Drainfield Material(Alternative or pert.pipe) €e-a„t: v <br /> Total Drainfield Footage I St" Trench Depth Minimum'X.`[i(Maximum ,'1/2 0. <br /> Curtain Drain Depth Signed <br /> Effluent Pump: Pump Model Ot-U..[-O )t 0_ . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: ta"K-1)t t1— S..a.4)-k•'C5 <br /> ATT Make and Model Ay [Z�� (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 6._1')-J <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 i : I I Approved [ ] Approved with corrections:see inspection report [ ]Denied <br /> Signed: Title: , Date: <br /> MC:S-41 rev!3103;4/12;5/14; 11/17 G:\Forms\Septic\S-4I As-Built2015Version2017.doc WHITE:Marion County;/ELLOW.:Owner;PINK:Installer <br />