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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.555-24-002398-PRMT <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PWBuildingInspection <br /> Rib ADDRESS: 10351 N Fork Ln <br /> Lyons,Oregon 97358 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale:1"=_' r' T <br /> North <br /> See Attached <br /> SU. <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 /> System Design Sewage Flow 375 Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> 1500 2- STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> Septic Tank:Size Comp gallons Mat'I Concrete Mfg Willamette Graystone DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size gallons Mat'1 Mfg <br /> [>]I have tested the septic tank and certify it to be watertight. <br /> ATT Make and Model Box(es): <br /> [ ]Distribution The system was installed by: <br /> Effluent Sewer:Size t-va- Mat'1 PVC [ ]DrOP [ ]Property Owner(permittee) <br /> [ ]Concrete [x]Licensed Sewage Disposal Service <br /> Drainfield Pipe:Size a Flew [ ]Plasticc <br /> Material:Header Pipe Perforated Pipe_ DEQ License Number: 38988 <br /> Total Drainfleld Footage 105 Trench Depth Minimum to Maximum 36 DEQ Certification Number: RI792 <br /> Rock Depth:Total Under Pipe Curtain Drain Depth <br /> Alternative Drainfield Materials <br /> EZ Flow Signed: <br /> Effluent Pump: Pump Model rr 300511 Company name: New Creation Contracting <br /> Pump Cycle minutes minutes (please print) <br /> Time on off Gallons per Cycle <br /> Attach an additional sheet for components and materials not listed above. Date: 7/28/24 <br /> (For Marion County Use Onl <br /> The above septic system has bee inspect by Marion County.The information has been determined to be accurate and the system is: <br /> ('Approved, [ oved wi corrections:see inspection report [ ]Denied <br /> Signed: Title:etf.. IA)i/01 Lj _ Date:Y./' 1 <br /> MC:S-41 rev:3/03;4/12;5/14 WHITE:Marion County;YELLOW:Owner;PINK:Installer <br />