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Nk,„,. MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> '"d'`-- 5155 Silverton Rd NE (to be completed by system installer) <br /> -=� -.V; SALEM OR 97305 <br /> - 503-588-5147 PERMIT NO. c5 z /- 06/plc PjeMy <br /> MARION / / , 1 J �,, ,/ p <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection SITE ADDRESS:/IO I 6)/ 1/er i2y .SE 7 i iecDe <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM .I - <br /> Scale: 1"=31 ' . T <br /> curoz.. 1Z. PAIK- North <br /> 201 <br /> /5-0 <br /> ISO' <br /> Zoi . <br /> D • <br /> F . <br /> /co 8-1 <br /> ___ - - <br /> A -c = liSI <br /> 6.5--. c <br /> eF7—c- - 7/' c.10 —' P <br /> (3,17 =q I l \ . <br /> • e - F;sq 1 . o1' . \ <br /> 13 <br /> O <br /> WELL <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALSJ' AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> y DesignSewageT�O Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: /00 0 total gallons single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> (��L G1QA(�STpN [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: _ - __ __,_ <br /> Material: _ CONOZE E— [ ] flow-through - - k I.have tested the-septic tank and ce`rtify-it to be watertight. <br /> Effluent Sewer:/L p QI/ Header Pipe:/1 U l/ The system was installed by: <br /> Size/Mat'1 7 / VC XI3 y Size/Mat'1 7 PVC 363 if ty¢Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe )Q Drop 9Q Concrete DEQ License Number: <br /> Pipe total depth F I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe)rZ 12L01 .) /2O/P— PE2 <br /> Total Drainfield Footage if SO L Trench Depth Minimum2q u Maximum3g1 <br /> Curtain Drain Depth Signed:_ _ iliA-- <br /> Effluent Pump: Pump Model - qe., <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: <br /> (please print) <br /> ATT Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: 9-2 Zy <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 [ ] Approved with corrections: see inspection report [ ]Denied <br /> Signed: 0/1417e"..---- Title: KENS Date: V �L/ <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20l5Version2017.doc WHITE:Marion County;YELLO :Owner;PINK.:Installer <br />