Laserfiche WebLink
iiiii' MARION 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. Z2_-CO53114 <br /> MARION <br /> COUNTY http://www.co.marion.br.us/PW/Buildinglnspection <br /> SITE ADDRESS: I tQG(3 . )c,,(4;tecA Oe Lify\s Off--- <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: ` <br /> Scale: 1"= ic <br /> North <br /> 4\ - t .5' Tru tise9A- Q.....o_ a. <br /> 0 p- r <br /> ,� A? `� 4 `.` 4 N J . V . q <br /> 1� _ <br /> : .emu �C` <br /> `c". 2-30`• sFla>v r - <br /> ctri (1--- <br /> y, .._-) F.,-..A,....a 91.sritaa>",.. <br /> tA - - _ <br /> It <br /> ._ <br /> . io ... <br /> .L.- .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 37c Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I cob total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> double compartment <br /> Manufacturer: w4;(,L <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Ise <br /> • Material: (Q✓tr/121-e_ [ ] flow-through I I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: `,n Header Pipe: u The system was installed by: <br /> Size/Mat'I 11 Sa..,'(0 Size/Mat'l 4 , t,i.t`!0 I I Property Owner(permittee) <br /> [)d Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) q <br /> Rock and under pipe I I Drop XConcrete DEQ License Number: Z 3U <br /> Pipe total depth MDistribution I I Plastic <br /> DEQ Certification Number:-LE fr`t <br /> Drainfield Material(Alternative or perf.pipe) <br /> c <br /> Total Drainfield FootageZZ0 Trench Depth Minimum le Maximun2S <br /> Curtain Drain Depth Signed:.____ <br /> Effluent Pump: Pump Model PF3 pc-6- . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: (d .2Dek;L] <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date:1 1 /F5/7.._ <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: [%4 Approved I I Approved with corrections: see inspection report I I Denied <br /> Signed Title: rr l I Gt3 g ro Date: CA/°'/Z Li <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />