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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 515S Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> 503`588-5147 PERMIT NO. rj j 5^o ..L`i—06 5 1 35— <br /> MARION <br /> COUNTY . http://www.co.marion.or.us/PWBuildinglnspection <br /> SITE ADDRESS: J o2s. e2.6 a rtinS bt (Qae 1-2,4 gt. <br /> AS-BUILT:PLAN OF CONSTRUCTED SYSTEM: rvni , OiL. 9.77 Z <br /> Scale: 1"_ • 44*- <br /> North '. <br /> • <br /> r <br /> 66 - IZ- <br /> A- 0 , 58' <br /> rolc- <br /> / ..\-- <br /> F <br /> y <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> L SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> G �vi.1L Gv./y I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN, <br /> System Design Sewage Flow 31/ Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I GGC7 total gallons [single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> I OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> - Manufacturer. (.th.tC [ ] double compartment <br /> Material: 14e-4,2-tG <br /> [ 1 flow-through I?ei I have tested the septic tank and certify it to be watertight <br /> Effluent Sewer: t r n Header Pipe: The system was installed by: <br /> Size/Mat'l !2tJC Size/Mat'l L^Xr,5lo5 [ I Property Owner(permittee) <br /> ['J,icensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe [ I Drop (+Concrete DEQ License Number.. D Ltd <br /> Pipe total d �`epth ' [XI Distribution I 1 Plastic DEQ Certification Number: 14740 1 <br /> Drainfield Material(Alternative or perf.pipe) — <br /> Total Drainfeld Footage — Trench Depth Minimum Maximum-- <br /> Curtain Dram Depth_ — Signed: - <br /> Effluent Pump: Pump Model . . <br /> ; Pump cycle �t' <br /> times in minutes: on _ " off — Gallons per Cycle — Company name: Ote-e.(d�. 'x-4v'w 7'- ;i.e..., •LL-C <br /> AU Make and.Model ---- (please print) <br /> Attach an additional Sheetfor components and materials not listed above. Date: —a2�`A./ <br /> (For Marion Cou ntyUse.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:see inspection report I I Denied <br /> Signed: X�� Title: IEl L, Date: A/l,J/ At <br /> MC:S-41 rev:'3/03;4/I2,5/14;11/17 G:1Forms\Septic1_S-41 As-Built20l5Version20l7.doc WHITE:Marion County:YELLOW:Owner:PINK:Installer <br />