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amMARION COUNTY BUILDING INSPECTION <br /> 555 COURT ST NE/PO BOX 14500 <br /> MARION SALEM OR 97309-5036 INDIVIDUAL ONSITE SEWAGE SYSTEM RECORD <br /> COUNTY (to be completed by system installer) <br /> / <br /> SITE ADDRESS: ) 7 9- H A4027--Lfl PERMIT NO. S,5 r" 2C�'���5;39-fmr <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale:l"= <br /> Nora <br /> • <br /> ► 4111111 <br /> cp.),1w` <br /> 0'? • -"J.\ _ / <br /> - 3NAtirp I <br /> Ti- <br /> t <br /> AV <br /> ' SITL all dills 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: Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br />. <br /> f STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> Septic Tank:Size: 54"17 <br /> 9a I Mat'1 fif <br /> /r Mfg:L/4v/1-440/ DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size: Mat'l Mfg: [J I have tested the septic tank and certify it to be watertight <br /> t <br /> Effluent Sewer:Size: f I'' Marl:i.A c/a The system was installed by: <br /> [1 Property Owner(permitee) <br /> Binges): Itribution; I]Drop / Concrete; [J Plastic [1 censed Sewage Disposal Service <br /> Drainfield Pipe:Size: :Material:Header: ;Pert': DEQ License Number: 3t-0--3 I <br /> DEQ Certification Number: Z6 k- <br /> Total Drainfield Footage: ;Rock Depth:Total: ;Under Pipe: �CW/ � <br /> Signed: F� !Y/( <br /> Alternative Drainfield Materials: 1 <br /> Trench Depth:Minimum: ;Maximum:_ ;Curtain Drain Depth: Company name:_ r q$7 f y <br /> ^' n�/ (please print) <br /> Effluent Pump:Pump Model1tD ' ;!Static Head in System Ft. � �[,/ <br /> Date: k <br /> Pump Cycle Time: ;Gallons per Cycle: <br /> Attach an additional sheet for components and materials not listed above. <br /> (For Marion County Use Only) <br /> The above septic system has been inspected by Marion County.The information has been detemuned to be accurate and the system is: <br /> [(Approved <br /> [ J Approved with corrections:see inspection report <br /> [}Denied IA I r {�` Q► <br /> Signed: QA1Yl/\3MIU P i 'J V 9� Date: U I (D46 <br /> MC:S-41 WHITE:Marion County; YELLOW:Owner;PINK:Installer <br /> rev: 8/00,6/01;3/03 <br />