Laserfiche WebLink
S*ITE~ ~DDRESS: <br /> <br />INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> <br />; PERMIT NO. <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />scale: 1" = <br /> <br />[ <br /> <br />Nor th <br /> <br />,+ <br /> <br />(show all details and dimensions necessary to locate all components of the system in the future) <br /> <br /> SYSTEM MATERIALS AND SPECIFICATIONS: <br /> <br />Septic Tank: Size:~Mat'l: ~f Mfg: <br /> <br />Dosing Tank: Size: Mat'l: Mfg: <br /> <br />Effluent Sewer: Size: <br /> <br />Box(as): [ ] Distribution; <br /> <br />Drainfiald Pipe: Size: <br /> <br />Total Drainfield Footage: <br /> <br />Trench Depth: Minimum: <br /> <br />Effluent Pu~: Pump Model: <br /> <br /> Mat'l: <br />[ ] Drop / [ ] Concrete; [ ] Plastic <br />; Material: Header: ; Peri: <br /> <br /> ; Rock Depth: Total:__; Under pipe:__ <br /> <br />; Maximum: ; Curtain Drain Depth:__ <br /> ; Static Head in System: <br /> <br />ft. <br /> <br /> Pump Cycle Time: ; Gallons per Cycle:__ <br />Attach an additional sheet for components az~d materials not listed above. <br /> <br /> INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY TEAT THE ON-SITE SEWAGE <br />SYSTEM INSTALLED AT T~E ABOVE ADDRESS WAS CON- <br />STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br />THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br />QUALITY COMMISSION. <br />~ I have tested the septic tank and certify <br /> it to be watertight. <br /> <br />The system was installed by: <br />[ ] Property Owner (permitee) <br />[~ Licensed Sewage Disposal Service <br /> <br />Company name: <br />(please print) <br /> <br /> Date: <br /> <br /> (for Marion County use only) <br />The above septic system has been inspected by Marion County. The information has been determined <br />to be accurate and the system is: <br />]Approved <br /> Approved with corrections: see inspection report <br />[ ] <br />$ig~ed .~ ~ ~ Title/~/~~~ Date: <br /> <br />as-built.frm 4/95 WHITE:Marion County; YELLOW:Owner; PINK:Installer <br />MC-15-S41 <br /> <br /> <br />