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INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system in~s~'~ller) <br />SITE AIII}I{ESS: ~~1~ /~ ~ ; PERMIT NO. <br />AS..BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />(show all dekaJls and dimensions necessary to locate all components of the system in the future) <br /> <br /> F~T~AL.,~ LIST FOR SYSTEM: <br /> <br />s~p~i~ T~k: size: <br /> Material: <br /> <br /> Haterial: <br />Box(es): T~e :__~ ~ F,., <br /> <br />~oa~er Pipe: Size: <br /> <br />Dis tr~.bution Pipe:Size: <br /> <br />Drain ~edJ. a: Depth:~;.~ <br /> <br /> ~NSTAI~LERscE~T~FiCATION: <br /> I HEREBY CERTIFY THAT TH~ ON-SITE SEWAGE <br />SYSTEM INSTAL6ED~AT THE ABOVE ADDRESS WAS CON- <br />STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br />TEE pERMIT AND TEE RULES OF THE ENVIRONMENTAl, <br />QUALITY dOMMISSION. <br />[ ] I have tested the:~ep~ic ~ank and certify <br /> <br />signed: <br /> <br /> (for Marion County use only) <br /> <br />be ac¢!urste and the system is~ <br /> Approved <br /> <br /> Denied <br /> <br /> <br />