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dibiMARION 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 /> s2--D 1!� j <br /> 503-588-5147 PERMIT NO. h (�J07/ <br /> MARION ,'�wY �/ 7j/f6 <br /> COUNTY http://www.co.marion.onus/PW/Buildinglnspection ���JJJ\�' 1 /i�// <br /> SITE ADDRESS:(� / �,/ , <br /> 'AS-BUILT PLAN OF CONSTRUCTED SYSTEM: �.1 C/(f144.21l Tan 913Z/ <br /> Scale: 1"= 150'' �•° T <br /> North <br /> SC)) il <br /> I <br /> .cif <br /> AI ($a .. ,.• •, t <br /> .A, . <br /> ,..,„ <br /> , 0,9.v.,,,, 1 _ ke.,,,,, sc, ms L <br /> • ,�,� ii 'DI p SO�(f� Stpik. <br /> 41 <br /> . ,• .. <br /> '4 cieo 1 Ill <br /> • <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 Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: <br /> double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through ['PI have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: // L,� Header Pipe: �� The system was installed by: <br /> Size/Mat'l ° C / �V�Size/Mat'l ,Property Owner(permittee) • <br /> I I 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: <br /> 1 Pipe total depth Distribution I I Plastic <br /> DEQ Certificatio IIr: <br /> Drainfield Material(Alternative or per &.(i pipe) ffL f CAe.43 <br /> Total Drainfield Footage 375 Trench Depth MTnimum27 'Maximun>�`s <br /> Curtain Drain Depth /✓/- Signe en / /1/1/ <br /> Effluent Pump: Pump Model *in. . <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: <br /> /13/4/— (please print) <br /> ATT Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: es ZV 0 3 <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: pproved [ I Approved with corrections: see inspection report [ ] Denied <br /> Signe tle: 0-1 , 3 $ Date: C/ 01,1'Uo <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 />