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J.' : ' <br /> INDIVIDUAL .ON-SITE SEWAGE SYSTEM RECORD <br /> MARION COUNTY BUILDING INSPECTION (to be. completed by system installer) <br /> DIVISION <br /> MARION 555 Coup St NE/PO Box 14500 <br /> COUNTY Salim,OR 97309-5036 �{ <br /> (503)588.5147 SITE ADDRESS: L ' t P1 1...) 1"-t A_ki 5 1-t ( --L- tQL T " . E- <br /> PERMIT NO. D.5— n'' n 4 J <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> scale: 1" .5,0 ' egf.-- 1 <br /> North <br /> t:t14C i <br /> l-e-1 <br /> tY <br /> ze' l <br /> i1 <br /> I i <br /> �'�� 9-o° fr l- ' I 1 tj <br /> - P , j a AA 2 <br /> ‘N � <br /> P <br /> (show all details and dim. sions ecessary to locate all component of the system in the future) <br /> SYSTEM MATERIALS AHD SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow: 450 Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br /> j �j f . SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br /> ' Septic Tank: Size: !S o Mat'l: COjt C ZT W E Mfg: Arr�- STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br /> THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br /> Dosing Tank: Size: Mat'l: Mfg: QUA;L , COMMISSION. <br /> �/ f .(fl•-. I have tested the septic tank and certify <br /> Effluent Sewers Size: 2 Mat'l: Si? ��O PVC. it to be watertight. <br /> Box(es): ( ) Distribution; [4 Drop / [W Concrete; [ I Plastic The s m was installed by: <br /> p L�I r,`` Q �� [ roperty Owner (perpmitee) <br /> Drainfield Pipe: Size: 7 ; Material: Header: I ; Perf: r L' u- [ ) Licensed Sewage Dis osa . Service <br /> Total Drainfield Footage: "J O; Rock Depths Total: L/ Under pipe: (� - DEQ License Number: <br /> Alternative Drainfield Materials: <br /> ale: 1'/ A 4 <br /> Y y• _A` Signed: � <br /> Trench Depth: Minimum: 2 ; Maximum: Z r ; Curtain Drain Depth: '/v/4 <br /> C,� r..l <br /> Effluent Pump: Pump Model:m F \fl ; Static Head in System; f v Ft. Company name: <br /> (please print) <br /> Pump Cycle Time: ` •'Yv. 1C)Gallons per Cycle: i71 <br /> Date: 1., 11 a 1 4 s <br /> Attach an additional sheet for components and materials not listed above. 1 <br /> (for Marion County use only) <br /> The above septic system has been inspected by Marion County. The information has been determined to be accurate and <br /> the stem is: <br /> [ Approved . <br /> [ ] Approved with corrections: see inspection report <br /> [ ] Denied <br /> ePIA-• <br /> Signed LW/Title: <br /> L_� Date: <br /> MC: S-41 WHITE:Marion County; YELLOW:Owner; PINK:In3 ller <br /> rev: 8/00,6/01 <br />