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MARION COUNTY BUILDING <br /> SI,VNPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> iiiii <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 : ,,., (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. 5_5-D1 f 0036 <br /> MARION � <br /> COUNTY •http://www.co.marion.or.us/PW/Buildinglnspection OS cA ,(� VC(SITE ADDRESS: t,`` (��. -7 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: PIA T� .l R q ` <br /> Scale: 1"_ T <br /> North <br /> - -e'g.) 0\1'6 jNO1 ill(\ti."\- -- . <br /> • <br /> ,r " <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 /> S2S I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> Systim Design Sewage Flow Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR • <br /> - <br /> TANK Size: OD total allons f single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ' �U'oa , �,"�C.J e [ I double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: � <br /> Material: c lefeke.... ". [ ] flow-through [ I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: t��1 Header Pipe: i% Thew system was installed by: <br /> Size/Mat'I ""1' Size/Mat'l up W�Property Owner(permittee) • <br /> _ [ [ Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe t 1 I Drop I)(Concrete DEQ License Number: <br /> Pipe total depth is-al [ 1 Distribution 1 I Plastic .e� �. DEQ Certification Number: <br /> Drainfield Material(Altemative or pert.pipe) l V6 4.11 'PQ.q'� '1 t�, <br /> Total Drainfield Footage Trench Depth Minimum 1 VI, Maximum <br /> Curtain Drain Depth Signed:, Icr►' <br /> Pump: Pump Model - . <br /> Pump cycle 'R ) • 1��� ;- <br /> Effluenttimes innmminutes:"on off Gallons per Cycle Company name: d <br /> ATT Make and Model (please print),V • <br /> Attach an additional sheet for components and materials not listed above. R'Date: -fa `- a <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 [ I Denied - ` <br /> 1 <br /> Signed: R "" Title: loTS3 7 °' Date: <br /> MC:S-41 rev:3/03;4/ ;5/14; 11/17 G:\Forms\Septic\S-41 As-Built20l5Version20l7.doc WHITE:Marion County; YELLOW:Owner;PINK:Installer <br />