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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> , SALEM OR 97305 <br /> 503-588-5147 PERMIT NO.MARION 555 24 003674 PRMT <br /> COUNTY http://vvww.co.marion.or.us/PW/Bui <br /> ldth,gInspeetion SITE ADDRESS: A17 11Aaarinwc I n SF,JaffPrcprl OR 97959 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale:1"_ ' '" T <br /> North <br /> See Attached <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 /> Design Sewage Flow 45n Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1pnp total gallons X.-single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer. wivamette GreystonP <br /> ['] dauble compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: Concrete [ ] flow-through [Xf have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'I 2"PVC Size/Mat'l [ ]Property Owner(permittee) <br /> -prLicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) -_ <br /> Rock and under pipe [ ]Drop [ ]Concrete DEQ License Number: 38988 <br /> Pipe total depth [ ]Distribution [ ]Plastic <br /> DEQ Certification Number: _p179P <br /> Drainfield Material(Alternative or perf.pipe) F7 flnw <br /> Total Drainfield Footage 150' Trench Depth Minimum Maximum <br /> Curtain Drain Depth_ Signed:_ <br /> Effluent Pump: Pump Model PF 300511 <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: New Creation Contracting <br /> ATT Make and Model Orpnr.n AX20-RT (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 7/1 S/94 _ <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: [Approved [ ]Approved with corrections:see inspection report [ ]Denied �y <br /> Signed: Title: R // Date: /97/Q9 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Fonns\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW-Owner;PINK:Installer <br />