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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> iiim <br /> 5155 Silverton Rd NE SALEM OR 97305 (to be completed by system installer) <br /> 2 <br /> MARION 503-588-5147 PERMIT NO. , J- 006 o 1 ,COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 3E;110G1f "4 c icls W-, 4/0/1 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"_ T <br /> de,yVic, 1 O(` North <br /> / \-C/P/If-:1 <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 Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: \ --(30 `` �, total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: Lie,"'T'C 7 [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: (,!A,(,.-reAA- [ ] flow-through I ]I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Reader Pipe: The system was installed by: <br /> Size/Matl Size/Mat'l I I Property Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> •DRAINFIELD rock depth(inches) Box(es) ��-�+ <br /> Rock and under pipe 6 0 1 I Drop I I Concrete DEQ License Number: �= <br /> Pipe total depth 12 h I I Distribution I I Plastic - <br /> DEQ Certification Number: : z``- •_2;J <br /> Drainfield Material(Alternative or .eirpipe) <br /> a/ <br /> Total Drainfleld Footage-ti Trench Depth Minimum_ Maximum_ <br /> Curtain Drain Depth Signed:_ aNt1/ <br /> Effluent Pump: Pump Model V?3d t l ele rr c <br /> Pump cycle2� '" �� _ <br /> times in minutes: on '\(u* off Gallons per Cycle 3C) Company name:_" 71 — -tE tek <br /> (please print) <br /> ATT Make and Model � + �� <br /> Attach an additional sheet for components and materials not listed above. Date: ��\` - <br /> (For Marion Coun a Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [i�pproved [ ]Approved with corrections:see inspection report [ I Denied <br /> Sign - - if! Title: r lT Si (D`J�'?� �' Date: 62150f <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW.•Owner;P NK:installer <br />