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AftMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. 24— 00 5 i elm <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection <br /> SITE ADDRESS:QLSZ LakYbh UAW rol tqg <br /> 'AS-BUILT PLAN OF CONSTRUCTED SYSTEM: �uQTfi1n/ R' '113 1 <br /> Scale: 1"_ 50' 'I• T <br /> North <br /> i <br /> t Pt - E _ 1.o.Z ' . <br /> 3 / z ' <br /> bi W` CD <br /> _ <br /> � _ 0 <br /> v,• <br /> - - / <br /> .,. <br /> 0 <br /> ,.o to' M lb • <br /> 0. <br /> (- <br /> f <br /> � ` 0 -\i <br /> t <br /> l\ '` k <br /> `\ <br /> ‘ • <br /> o <br /> t, C <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 31 5 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1000 total gallons Pc.single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer:U)oi]'{. <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: &Met l'_. [ ] flow-through i pi I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: a Header Pipe: �i The system was installed by: <br /> Size/Mat'l Pit{ QUL Size/Nat'l I•� Qv c 3631 I I Property Owner(permittee) <br /> ILicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe Li," ly[Drop IN Concrete DEQ License Number: ;391 ti I-{ <br /> Pipe total depth IL'1 I I Distribution I I Plastic <br /> pc <br /> Certification Number: I SSG <br /> Drainfield Material(Alternative or perf.pipe) ` e in <br /> Total Drainfield Footage 3Gr1f Trench Depth Minimum Gy Maximum 9.6. <br /> Curtain Drain Depth_/to%4... Signed: <br /> Effluent Pump: Pump Model pP3(205I I <br /> Pump cycle <br /> times in minutes: on off _ Gallons per Cycle Company name:_ SC 63(C a Uahn3 L-1. (i <br /> All'Make and Model no n(- (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 2c/Zd z- <br /> (For Marion Count se 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 I Approved with corrections: see inspection report I ] Denied <br /> Signed: Title: e T ioZ3�9R--�' Date: I V • b <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:Ou'ner;PINK:Installer <br />