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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 �1 <br /> 503-588-5147 PERMIT NO. S6 S —' g I —OM t 0 6—prM+-f9 f <br /> MARION COUNTY http://www.co.m f� <br /> arion.or.us/PW/Buildinglnspection SITE ADDRESS: i as 5© �U,E �'l fi <br /> erg LIT 5 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: �-yona CJ/L 73Se <br /> Scale: 1"—— , T <br /> North <br /> 19e,r- Io r-l/ LiV <br /> \ ( f==7 . . <br /> r 1 ri /.G <br /> lank o-F" Cor re-c] <br /> k4 1.- l+evcIs <br /> IF '4 <br /> L x. - sit i <br /> � q' O <br /> "ro-rk 7\ ,,,vec, <br /> D <br /> .....„ <br /> _ _ <br /> � I CIS.onl- <br /> n' `r11,-11 v J-i r-e IfDm e. <br /> V . <br /> ' f I <br /> f <br /> (show all details and dimensions necessary to locate all components of the system in the future) I <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> • <br /> System Design Sewage Flow 3 ar 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 070 total gallons Del single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: pi a,5 tit, [ 1 flow-through 1}1•I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: i/ �.,�.. Header Pipe: The system was installed by: <br /> t( <br /> Size/Mat'l ti") . , , Size/Mat'l /'c�j5' M•Property Owner(permittee) <br /> J_ h I ] Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe ' I I Drop l l Concrete DEQ License Number: (3 9 1 q 0 <br /> Pipe total depth_ _ .Distribution r>k Plastic DEQ Certification Number: ! 1 l <br /> V." <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage '14 I I. Trench Depth Minimum Maximum �/ /, I <br /> Curtain Drain Depth- Signed: /.pt j, ij ! V�/ <br /> Effluent Pump: Pump Model f\�,HQ}-� . d <br /> Pump cycle II ) - L <br /> times in minutes: on _off Gallons per Cycle Company name:_ C�/'«� S `G�-{ L- <br /> ATT Make and Model lease print) <br /> Attach an additional sheet for components and materials not listed above. Date: `f ' p?)`{' <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 sy tem is: [l.}Approved a [ `Ap. oved with correction : see inspection report [ I Denied <br /> Signed: WI V1 ►I.1 . / OlvA Title: 4' 9 • Date: 1 I (• <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015 Version20l 7.doc WHITE:Marion County; YELLbW:OJner; INK:Installer <br /> t <br />