Laserfiche WebLink
INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) �f`� <br /> SITE ADDRESS' 6 ERMIT NO. q' — // <br /> AS-BUILT PLAN OP CONSTRUCTED SYSTEM: <br /> scale: 1" _ T <br /> North <br /> . <br /> • <br /> • <br /> • <br /> j;ka cycap; 7---;74,14- ,i _ii,f0Y-97'/ilic444fa-' <br /> j),..e.A7/* IridoeffefercALAA ..... fie.40,4 &-6-e ------ <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM wATERIALS AND SP�CIPICATI INSTALLERS CBitTIYICATION: - <br /> /.3�� ll // ' I HEREBY CERTIFY THAT THE ON-SITE SEWAGE- <br /> Septic Tank: Size: Mat']: ,it0 1+Ifg: j,(/ SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br /> STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS-OP <br /> Dosing Tank: Size: Mat'l: Mfg: THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br /> � ,/ QUALITY COMMISSION. <br /> Effluent Sewer: Size: a Mat']: l/t G[O�1Q NJ I have tested the septic tank and certify. <br /> %%% it to be watertight. <br /> Box(es)s X Distribut••n; ( ] :,:op / (Concrete; ( ]'Plastic <br /> The system was installed by: <br /> Drsinfield Pipe: S' .[�;Vir"," '''' Header: ; Perf: [ J Property Owner (permitee) <br /> [ ] Licensed Sewage Disposal Service <br /> Total Drainfield'aootage(J[a zo'" o <br /> ; Rock Depths Total:N/�; Under pipe: <br /> Trench Depth: Minimum: ` ; Maximum: l�; Curtain Drain Depth: Signed: gr-i' ' C <br /> Effluent Pump: Pump Model: e Sr Jo( ; Static Head in System:el c ft. Company name: 8/L/ / l i_�e <br /> (please print) <br /> Pump Cycle Time: / N/. Gallons per Cycle: /� I <br /> Attach an additional sheet for components and materials not listed above. Date: <br /> {for Marion County use only) <br /> The above septic system has been inspected by Marion County. The information has been determined <br /> to be accurate and the system is: <br /> (l4 Approved <br /> [ ] LAppr• •-•1 it c••rrections: see inspection rep rt <br /> [ ] Denied P•, — ` <br /> Signed: �1 1 , L,.,11A Title: Date: i 4 • <br /> as-built.f '• 5 ' WHITE:Marion County; YELLOW:Owner; PINK:IAstaller <br /> MC-15-S41 . • <br />