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dimMARION 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. 5.55- 1.4 Q,OL-tk 58 <br /> MARION <br /> COUNTY , http://www.co.marion.or.us/PW/Buildinglnspection , 1 <br /> SITE ADDRESS:��?jy �G've�� N►�y�� (ltiY\fu\S i2c;1 �L <br /> 'AS-BUILT PLAN OF CONSTRUCTED SYSTEM: (lZVJC\1S ( 2... C 00 b <br /> Scale;_11'...7-- __ ..__._.�._ _...._.•_ T_..._. <br /> {� <br /> LLL <br /> : '-leci - . <br /> N t c x lio - to lu i0 1 <br /> tti t—L <br /> -... <br /> s- c(/ 3 4 <br /> r <br /> • <br /> N <br /> v) L. tj \\s.s........s.... <br /> S00 E+ 3 <br /> 1. 4, II c° 11:h - S <br /> 0 <br /> r 3. S. 1 Iof io 9er <br /> 4. 5 -Z t s 1'" 1'"0 <br /> . 5. 3 It, ih 1)t1° <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 j?G Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1500 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: i k� <br /> [ ouble compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: (✓(l6'\C v't.Irk— <br /> [ ] flow-through kilhave tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pip�j; f!^ Th system was installed by: <br /> Size/Mat'! 1 /Lf ]PS SCiI /0 Size/Mat'l / DWV IPS$UlLIO 1lhee Property Owner(permittee) • <br /> / I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe V 1 Drop Concrete DEQ License Number: <br /> Pipe total depth I I Distribution I I Plastic <br /> -7 DEQ Certification Number: <br /> Drainfield Material(Altemative or perf.pipe) 1 '2,— (low <br /> Total Drainfield Footage -;$1) Trench Depth Minimum 12, Maximum l <br /> Curtain Drain Depth Signed:_ bs /4 Vel <br /> Effluent Pump: Pump Model l.'6" pu(h es . <br /> Pump cycle J <br /> times in minutes: on off Gallons per Cycle Company name: <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: ��� 2q <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 /> Signe3� Title:!'31 iO ,3__ DategliVZ <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County; YELLOW:Oivner;PINK:Installer <br />