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. <br /> r <br /> • <br /> 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. 55 5 —Z4— 0011 t7_ e g,, , <br /> MARION <br /> COUNTY htt //ww.co.maron.or.us/PW/Buildin Ins ection <br /> p� w i <br /> g p SITE ADDRESS: 1328 7 ();G0.Ca e k .569 1 tArdkey <br /> 'AS-BUILT PLAN OF CONSTRUCTED SYSTEM: oR Q73 <br /> 12 <br /> Scale: 1"= 1'0' • , 0 1' <br /> ®OO°. North <br /> t <br /> /... <br /> 0 <br /> 0 <br /> f <br /> $ •e <br /> ►Y a ,c• <br /> O! . .41, ,, <br /> tli L✓ J' <br /> • <br /> 9 ,, 9� <br /> p . <br /> 8 <br /> goo <br /> .e, , 8 <br /> • % $ -.,, 23' - - - 15s <br /> -p __ <br /> FE,�eE / O Et�N� LONE. — - <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 /> �0 Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow 1 STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 110 60 total gallons pljf single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: in 4 e,‘s erck.kor [ 1 double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: ?a ty . [ I flow-through p4 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer ea Header Pipe: 0The system was installed by: <br /> Size/Mat'I 1 S0I 35 Size/Mat'l Lif )'Property Owner(permittee) • <br /> - [ I Licensed Sewage.Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: OVA <br /> Pipe total depth ap4 Distribution I I Plastic <br /> DEQ Certification Number: I A • <br /> Drainfield Material(Alternative or pert'.pipe) E2 FL®t) . <br /> Total Drainfield Footagep�� �s <br /> g ��� Trench Depth Minimum Ir7 Maximum 2® <br /> Curtain Drain Depth o Signed: <br /> Effluent Pump: Pump Model . <br /> Pump cycle <br /> times in minutes: on o off ® Gallons per Cycle Company name:_ i J/f1/4 <br /> ATT Make and Model o (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: a as <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:co' ctS see inspection report [ I Denied <br /> Signed: 1 Title: �I�( l Date: + 4ii <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 />