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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 Q _ q a <br /> MARION 503-588-5147 PERMIT NO. ( l G o ( 1 Q 1 pg_M <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection I y'it° g �Jowl5 (jag?' e'r)- N E <br /> SITE ADDRESS: �7 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: S '( V '�r•l al Q-?Y <br /> Scale: 1"= O. <br /> -1401h <br /> 4a <br /> -Q s'° if .) • <br /> r <br /> 10' •< <t p_ t 40rf <br /> C], <br /> Jt , <br /> d <br /> �r s . <br /> Ot14 .. , <br /> 'i''r9.7 11 <br /> (show 11 details and dimensions necessary to locate all,components of the system in the future) ,34s-- <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow l s o Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I 00 0 total gallons ingle compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> LA) �.�-�. [ ] double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: <br /> Material: CO 1•••CAre+e, f ] flow-through 1 ]I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Q /Ii Header Pipe: The system was installed by: <br /> Size/Mat'l 1"C�a IA-)e `#5 Size/Mat'I roperty Owner(permittee) <br /> icensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) . <br /> Rock and under pipe mr Drop Concrete DEQ License Number. <br /> Pipe total depth 4 11 Distribution 1 I Plastic <br /> O DEQ Certification Number: . <br /> Drainfield Material(Alternative or pipe) �� w <br /> Total Drainfield Footag ✓! / Trench Depth Minimumt'i Maximum-3 D <br /> Curtain Drain De th 1 Signed:_ QQ (� <br /> p �d19,S 3bp On 00314 <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: <br /> All'Make and Model ( print Attach an additional sheet for corn..• • and materials not listed above. Date: 6 `(ppleasse� t• ` rt` 9 - <br /> (For Marion Coun j,.'e Only) T e above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: ►� : proved [ ]Approved with c rrections:see inspection report [ I Denied Signed: � � q Title: Date:' 'A l 1 <br /> MC:S-41 rev:3/(r;4/12;5/14;11/17 G:\Fonns\Septic\S-41 As-Built201 Version2017.doc WHITE:Marion County;Y LOW:Owner;PINK Installer <br />