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giiiiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEItECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> 5 3-SALEM IVI: <br /> 97305 <br /> 8- 14 PERMIT NO. T -)-14� e 303 <br /> MARION <br /> COUNTY http://www.co.marlon.or.us/PWB SITE ADDRESS: Cr�vuiidinginspection dp�JI � �+ 1.4 i q 16 <br /> � M �'t J�� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"__' T <br /> North <br /> k o a It1 tS l3Lij j T 4Y0 din.9 10 i Lii pec10 r a144 idCb CtCCeprt� <br /> `how all details and dimensions nece ssa 'to locate all components of the system in thef_uture) <br /> ___ SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION; <br /> r f I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow -1 50 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED 1N ACCOR- <br /> TANK Size: 1 C O total gallons [VJ single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: W i Bost ere f t'fe•?.j1(}h't� <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: CdnTgl� <br /> Cl" J [ ] flow-through I'll have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer; d Header Pipe: The system was installed by: • <br /> Size/Mall 114 SA ( arc SizeiMat'l 1tin 3d'34 I )Property Owner(permittee) <br /> . - itil Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Ruck and under pipe C.M I I Drop (V]Concrete DEQ License Number: 3S it1 4 <br /> Pipe total depth Ia-in Ni]Distribution [ ]Plastic <br /> DEQ Certification Number: 35.6.7 <br /> Drainfaeld Material(Alternative orperf.pipe) 10v1r F ppei , <br /> Total Drainfleld Footage.i SO Trench Depth Minimum ]l. Maximum. <br /> Curtain Drain Depth-)( Signed:_ .� v <br /> Effluent Pump: Pump Model <br /> Pump cycle `` <br /> times in minutes: on off Gallons per Cycle Company name'_ Ko ekn d hd J0 t <br /> (please print) <br /> ?err Make and Model Ditivon 1i el. k3,10 Skr T3 <br /> Attach an additional sheet for components and materials not listed above. Date: Zl tt )- _ <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The in orn tion has been determined to be accurate <br /> and the system is: L4Approved • [ ] Approved with corrections:see inspection report [ I Denied <br /> � a _ _ �j7� �j W/?7,39 <br /> Si ed: rI Title: !'\(%� / Date: <br /> MC:S-41 rev:3/03;4/I2;5/14;11/17 G:1Forms\Scptic\S-4 I As-Built2015 Version2017.doc WHITE:Marion County:YELLOW:Owner;PLNK:Installer <br />