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iiiiMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 - PERMIT NO. Zit—op c2 77 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: /R 7Z4 84thlCIli'/ie Re71. <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: r4zrrorm. DMZ 97062 <br /> Scale: 1"= p/.'"-_ T <br /> North <br /> il\ im I16 I <br /> o _ <br /> R <br /> r ., <br /> 14 _ N, • >2 sfo <br /> 320 ' e►eei -, pyrmaeRTy uAir <br /> vJoI] 4, <br /> Q <br /> 30 ' v /25 <br /> \,t <br /> 2 4:'-oP r,14" Scat 1ro <br /> /500 faga..7 r,!. D ' <br /> W4-/ re Co::•?C1 d- n lc. <br /> . i PA— <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALSIA AND SPECIFICATIONS: - INSTALLERS CERTIFICATION: <br /> y Design ✓� Gallons/Day 'I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Sewage Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> /5D 0 [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> TANK Size: ,'n total gallons OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: l,(/ade . ['7 double compartment <br /> Material: Co nc [ ] flow-through 140Kave tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'I Size/Mat'l [ I Property Owner(permittee) • <br /> Irricensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) d 9759 <br /> Rock and under pipe & I I Drop I I Concrete DEQ License Number: <br /> Pipe total depth /2 - I stribution IrKstic <br /> DEQ Certification Number: 1 33 i 1/ <br /> Drainfield Material(Alternative or pelf.pipe) <br /> Total Drainfield Footage375 Trench Depth Minimum 1 Y Maximum 2-2- <br /> Curtain Drain Depth .4' Signe Gam(/""` t���The. <br /> Effluent Pump: Pump Model 0 re,ie0 PF 3Ooc// <br /> Pump cycle <br /> times in minutes: on -/ off Gallons per Cycle Company name:_E ✓ /L. ex C�VMT/ ' - <br /> ATT Make and Model Wok (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 7/26/2O,29 <br /> (For Marion Count se 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 I ] Approved with corrections: see inspection report [ ] Denied <br /> Signed-- I'le: HST 1O1J3 F Date: etia/z4. <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version20l7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />