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dili] MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. £5 5 - ;A - 00 0 A 0.8 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 2N.Ag 0 6 iktlin i1z. AA. ES/-�-- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Ly 0.i.5 CIAL !c 735 <br /> Scale: 1"= 1 6p' - T <br /> North <br /> A i3 -- t 2 ' - <br /> ;,,74.-\ . <br /> c, <br /> r <br /> . C� <br /> '- • a s, i <br /> I� <br /> r. <br /> 3 <br /> . ,A(' <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 /> ,sue I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow 15 0 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I S '7 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> I OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: ��q.i(,'l-1-__ h9.^ double compartment <br /> Material: PO lyi y y Ieet c [ ] flow-through ' /have tested the septic tank and certify it to be watertight. <br /> Effluent Sewerit Header Pipe: The s stem was installed by: <br /> Size/Mat'1 ,a P 1110 Size/Mat'l j operty Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe 12. i/ I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth 15 °i [ I Distribution I I Plastic <br /> VLF <br /> Iy / ,^� DEQ Certification Number: <br /> Drainfield Material(Alternative or peril pipe) '( V� pV c' l 1.�6! <br /> Total Drainfield Footage Li 51 Trench Depth Minimum Maximum , watCurtain Drain Depth Signed: , ,,. t <br /> Effluent Pump: Pump Model1.0e. 1 IL ei� 1 E3 Q � /�, ^' <br /> Pump cycle Ht):m gd(A e�/ <br /> times in minutes: on `t off Gallons per Cycle_ Company name:_ VtIV <br /> (please print) ((( 6t( <br /> ATT Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: <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 I Approved with corrections: see inspection report [ I Denied <br /> 7 ��r <br /> Signed: Title: l` I�� Date: aR�� <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;PINK:Installer <br />