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Y <br /> • <br /> iiimiMARION 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. .5S Ou 5 — P — 9OC t O 6 r/9riyri--`f l <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection D�t <br /> SITE ADDRESS: f _l ilk;ivill ®t�./ LlV ,S'g <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Lyov O (-3735 <br /> Scale: 1"= T <br /> North <br /> v I I A.c <br /> c�.n k c-F Cor�rrr c <br /> W 0d-;r- L..e 11 cis <br /> t - r <br /> l G "1 l�`-r e `�i t <br /> i6 <br /> ,-�!/ d , �nl<'9` Dew <br /> r� <br /> 1 a'� (f cf1✓ If Cfea/�ova <br /> If to <br /> I' <br /> ✓_'`� . <br /> t <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 . if Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: ` i<L 0• total gallons De.]..single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: pl�5 17t, [ ] flow-through Jl.I have tested the septic tank and certify it to be watertight. <br /> The system was installed by: <br /> Effluent Sewer:�/!/ Header Pipe: Pro ert Owner(permittee) <br /> 1 ! topli-,e�,�-c.� Size/Mat'l �?e0s [, P Y (P ) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) (�j <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: 3 / q <br /> Pipe total depth KDistribution IAPlastic DEQ Certification Number: Aiq R, <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage 1.4 I r Trench Depth Minimum Maximum �/ �� /2 <br /> Curtain Drain Depth Signed: /,.,j_,{,L/ �'✓(// <br /> Effluent Pump: Pump Model I�\'ilk —ff <br /> Pump cycle �1 �t j <br /> times in minutes: on off Gallons per Cycle Company name:_ e—ear/ $ I Gam./C_ <br /> ATT Make and Model �/ lease print) <br /> Attach an additional sheet for components and "I'materials not listed above. Date: (s �" ' <br /> (For Marion County se Only) e a septic system has been inspected by Marion County. Th information has been determined to be accurate <br /> and the system is.: .[l�Approyed . I Ap oved with correction : see inspection report I 1 Denied <br /> Signed: `Wf V\ Title: LIT-4JO I 'f-TTI Date: ' ne <br /> i5 3-(' <br /> MC:S-41 rev:3/03;4/12•5/14. 11/17 G:\Forms\Septic\S-41 As-Built20l5Version20l7.doc WHITE:Marion County; YELL W:O1 r•PINK:Installer <br />