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iihiMARION COUNTY BUILDING INSPECTIONSA INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> 5 3-88EM OR4 97305 PERMIT NO. 5.55-211—60 z 13 Z - 2 R/1 1- <br /> MARION • <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection .;y� Vv® SC <br /> SITE ADDRESS: I I Z 7 g �f c� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Gir-LiIA10.e. G <br /> Sca e: 1"= T <br /> Y N.,./&11 North <br /> not <br /> 6J6'VGyd1 <br /> N.„ <br /> gsi e„.v old <br /> Sty ^ <br /> - v®c, <br /> . i <br /> )..... — <br /> i <9./-- 0' " <br /> 2 too ry <br /> ( ,I.,e.cy._.fr I-NA .4....,... . — — ——,---____——' <br /> Ai <br /> So, Q; .=,`sa . <br /> \- 0- ,I . .,,1 e. 0,-r. ,Lll <br /> (show a l 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-[-O- Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANKSize: / c7r� total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> �,-rtf <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: 1, <br /> Material: G c.6(. _ [ ] flow-through [)QI have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'I Size/Mat'l , [ I Property Owner(permittee) • <br /> [4-Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) // <br /> Rock and under pipe (�e® b I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth 11®e I I Distribution I I Plastic �� <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or peril pipe) <br /> Total Drainfield Footage i GO_ Trench Depth Minimum 211 Maximum ?C? ,-,Curtain Drain Depth Signed:_ „„ .e.,.... <br /> Effluent Pump: Pump Model • <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: C f ic( b ea 1 / j- <br /> ATT Make and Model ��Jplease print) <br /> Attach an additional sheet for components and materials not listed above. Date: '// 1LJ'/ <br /> 9 <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 [ ] Denied <br /> All <br /> Signed: / • Title: ICI 1 ' Date: 6/1�' <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 />