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i iiii 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 /> 503-588-5147 PERMIT NO. �—r"l_OQSIMA-(U <br /> MARION <br /> COUNTY p: www.co.maron.or.usungnspecon <br /> ` htt // i /PW/Bildil ti SITE ADDRESS: 6 L°1 q 1 S�{ �It/l�_ ►2 c.l ,S <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> 5o t� oz-- `{ C`3CJ Z <br /> • <br /> Scale: 1"= II <br /> North <br /> v-1 1 <br /> V <br /> Is- <br /> crl _ 1(� r � .. <br /> 2.0.4. OSA ---... . A , G� , <br /> . I V\ f.)-1/4.' i . rs' <br /> .� i r <br /> r <br /> 4t 5-1 t -A 6' , Sd , 3� l <br /> •t q W <br /> ` 10 <br /> 8 <br /> (show all details and dimensions necessary to locate all compone t fthe 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 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: l UW total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OFENVIRONMENTAL QUALITY COMMISSION. <br /> double <br /> Manufacturer: [ ] compartment <br /> Material: ,,/1.G,itl+V_ [ ] flow-through have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'1 Size/Mat'l I I Property Owner(permittee) • <br /> [tRicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop [Concrete DEQ License Number: 3 93 6 <br /> Pipe total depth I Distribution I I Plastic <br /> DEQ Certification Number: _ S1-"(Q <br /> Drainfield Material(Altemative or perf.pipe) 2 e <br /> Total Drainfield Footage i J'Q t Trench Depth Minimum icry Maximum3 1 <br /> Curtain Drain Depth_ Signed:_ <br /> Effluent Pump: Pump Model <br /> Pump cycle _ <br /> times innminutes: on off Gallons per Cycle Company name:_ if// <br /> YC- <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: <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: 'Approved I ] Approved with corrections: see inspection report I I Denied <br /> �= 25/ <br /> Signed: fl__-_ Title: �� Date: �� <br /> MC:S-41 rev:3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE.:Marion County; YELLOW:Owner;PINK:Installer <br />