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/- <br /> • <br /> 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 r �j y� <br /> 503-588-5147 PERMIT NO. S.55 —2 1 -c 3 6S p 3" 1 ? t r <br /> MARION ..--, <br /> CCOUNTYhttp://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: bac( 7'`�i�I � Yv p <br /> Q /1./� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: `c, letn, <br /> Scale. 1"_11 v ' viGel North <br /> [ <br /> ,01.ce\ . 4--t -7 Nei 1 <br /> e Oo- <br /> - <br /> � 11-6 <br /> & - I.:_ S ' <br /> f- 0 <br /> N a • <br /> N - - . <br /> a .y1 <br /> M -,1iy - . <br /> ‘A61 11,4 <br /> \ S6 • <br /> VI Ccpiard <br /> PAP <br /> (s -5 1 d <br /> ' e ba <br /> t° 70 3 <br /> 11?r__ - -- _. t <br /> � _ _� _$O - to __ - - - - - - -" - - <br /> ►13 , <br /> . 'b (00' <br /> 5 o' Y S' I i 0' 21i/.53 <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 /> IN- <br /> System Design Sewage Flow L I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> S y g g I,5D Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: e."413J-1 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through [ I I have tested the septic tank and certify it to be whtertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Nat'l Size/Nat'l [ [ Pro ert Owner(permittee) <br /> [Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe b 1)1-Drop {,Concrete DEQ License Number: <br /> 36I /6 <br /> Pipe total depth I2.'' I I Distribution I I Plastic 3 <br /> DEQ Certification Number: <br /> Drainfield Material(Altemative or perf.pipe)Total Drainfield Footage il10 Trench Depth Minimum Vi Maximum2.6 <br /> Curtain Drain Depth Signed: (3 &( <br /> Effluent Pump: Pump Model . <br /> Pump cycle times in minutes: on off Gallons per Cycle Company name:_ c3e4 .eil _,C(1,41•di,/ <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: -2 / 11/2!! . <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 is: 4Approved I I Approved with corrections: see inspection report I ] Denied <br /> Signed: t�t� Title: /�� ` Date: ��7��/ ' <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20l5Version2017.doc WHITE:Marion County: YELLOW:Owner;PINK:Installer <br />