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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> "db-- 5155 Silverton Rd NE (to be completed by system installer) <br /> --"=%%- - •SALEM OR 97305 <br /> `--- 503-588-5147 PERMIT NO. a 4 O06&3 <br /> MARION <br /> COUNTY siEhttp://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: l'L) 7 1 Jr�' rVOYt f k.out C S <br /> j <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' H <br /> .,, _ T <br /> North <br /> R ..e op ----_,,, <br /> Zf""n--i -- ;01, _____,..—..._ <br /> 0 Lb <br /> 2 ) d o 0 11 <br /> I \g <br /> 0- <br /> ,� _J o _ <br /> 0 <br /> —13-----o--0.132 II t tf 411 6-0" ' -1-- <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 ✓" 5Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I SO O total gallons X single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> ® ® 04 �? g� [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: GjiligfeitK re t 01'1e <br /> Material: (c t t'<' ,� [ ] flow-through X1 I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer:Li <br /> 1 Header Pipe: The system was installed by: <br /> Size/Mat'l !, �(�3 'J Size/Mat'l 9 303� I I Property Owner(permittee) <br /> 1 1 Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) Q <br /> Rock and under pipe [y4(Drop I I Concrete DEQ License Number: 31191 <br /> Pipe total depth I 1 Distribution I I Plastic <br /> DEQ Certification Number: F,-r 'do <br /> Drainfield Material(Alternative or perf.pipe) £2 t/ow <br /> µA��4 Total Drainfield Footage 0 Trench Depth Minimum al Maximum 36 <br /> Curtain Drain Depth_ Signed: <br /> 00 <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name:_ 1 61 <br /> ATT Make and Model (please print <br /> Attach an additional sheet for components and materials not listed above. Date: 9 X7 - 2.Ll_ <br /> (For Marion Count 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: pro- d [ ] Approved with corrections: see inspection report [ I Denied <br /> Signed: 7 Title: //-5 Date: co" 7/ccq <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 />