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• <br /> MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> . iiiii 5155 Silverton Rd NE (to be completed by system installer) <br /> 503-88-14797305 PERMIT NO. 55 5 41- o'5.3(0 <br /> MARIOH <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection <br /> SITE ADDRESS: I�G aDSSeiwfe,r LPN. <br /> AS-BUILT;PLANOF CONSTRUCTED SYSTEM: S.yr - I® 'L q 1 3 ss3 - <br /> Scale: 1"=+40 ' ' f <br /> North <br /> • <br /> • <br /> 1 4+ .f-t A< — — — --- — - — ._ tt ` . <br /> — _.. Ill — — [� 1 t <br /> r D5 t it <br /> J5r r <br /> • <br /> 5- 7ai tr, <br /> A <br /> Qij...-t 4-40 53` l J <br /> eke <br /> 47. <br /> E. <br /> 404\ l3c- 2L ' <br /> Rr-ZS,S ' <br /> k:1 <br /> `.,Fri74-k <br /> . 6 • <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 /> ?� Gallons/DayI HEREBY CERTIFY THAT THE ON-SITE.SEWAGE SYSTEM IN- <br /> System Design Sewage:Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> TANK Size: 6xisr total gallons OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: [ ] double compartment R <br /> Material: [ ] flow-through 1I I have tested the septic tank and certify it to be watertight: • <br /> • <br /> 1 ' Effluent Seven Header Pipe: f� The system was installed by: <br /> Size/Mat'l K Pt1C- Size/Mat'l PUU ( J Property Owner(permittee) <br /> Jad Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es). <br /> Rock and under pipe 1,4 A Drop pgConcrete DEQ License Number: 3 CsidoS-- <br /> Pipe total depth 1 Zrr I I Distribution I I Plastic DEQ Certification Number: az l' <br /> Draintield Material(Alternative or pert.pipe) Pt r-r-- <br /> Total Drainfield Footage -3501 Trench Depth Minimum Z.44 Maximum 36 <br /> Curtain Drain Depth ^ Signed: e... i <br /> • Effluent Pump: Pump•Model .-' <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle — Company name: ©lrcg.I', 5 at er..- 4-i�2+f- Lt:C <br /> ATT Make and Model J (please print) <br /> Attach an additional.sheet for components and materials not listed above. Date: - ✓ il __._ <br /> (For Marion Conn Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system i :' ' Approved I I Approved with corrections:see inspection report I J Denied <br /> Si ned: % Title: E F S Date: 5 e91f <br /> MC:S-41 revs3/03;4/12;5/14;11/17 G:1F 1 orms\Septic\S-4 As-Built2015Version2017.doc WHITE:Marion County:YELLOW:Owner;;PINK:Installer <br />