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, <br /> MARION COUNTY BUILDING•INSPECTION •• INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> iiikii <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. cgs" D t,l_ 00(o S 3`I <br /> MARION <br /> COUNTY .htt ://www.co.marion.or.us/PW/Buildin Ins ection G r� <br /> p g p SITE ADDRESS: 3 3 ikenc� 1/,S�a Pot S .�t+ersory <br /> 'AS=BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1" = ' (a, -\' \ --___1 N ' <br /> 4'"' 'Qovd.- way North <br /> C - IQI" <br /> D - Id" I <br /> • <br /> • F - act" • 62A.1C " <br /> Ora , <br /> 41 <br /> \boo <br /> 4, <br /> C" f\`f1''co* <br /> . I <br /> To ( p <br /> SI <br /> I <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 /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow LI CO Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1 S coo total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br />• Manufacturer: [ double corn p <br /> Material: -o vtCt`P.r�� [t] flow-through 1 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Matl Size/Mat'I I ]Property Owner(permittee) <br /> ]Off 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: 29 I P 7 <br /> Pipe total depth_ I I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) <br /> Total Drainfield Footage _ Trench Depth Minimum Maximum_ <br /> Curtain Drain Depth_ Signed: <br /> Effluent Pump: Pump Model �'ic" 3®®..g•I\/a I <br /> Pump cycle <br /> • <br /> times in minutes: on l Pg.') off 15 Min Gallons per Cycle Coo Company s U\tI e( k <br /> p� °� Corn an name:_ (/@. <br /> ATT Make and Model en1��ACD Axa o t T 1 a/3o (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: /s/./-/ <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:/1 Approved [ I Approved with corrections: <br /> see inspection report [ I Denied <br /> Signed: `� Title: /t. Date: 7/eyx?"? <br />• MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version20I7.doc WHITE:Marion County;YELLOW:Owner;PINK:Installer. <br />