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INDI[VIDUAL ON-SITE SEWAGE <br /> (to be completed by system installer) <br /> <br />SITE ADDRESS <br /> <br />AS-BUILT PLAN OF CONSTRUCTED : <br /> <br />scale: 1" = ' <br /> <br />RD <br /> <br />North <br /> <br />(show all details and dimensions necessary to locate all components of the s <br /> <br />in the future) <br /> <br />SYSTEM MATERIALS AND SPECIFICATIONS~ <br /> <br />Size: Mat' 1: Mfg: <br /> <br /> Distribution; [~rop / [ ] Concrete; [ ] Plastic <br /> <br />To'al D~atn£teld Footagm,~__.~)_; ~k Depth, Total: d~ ; unde~ pipe:~v <br /> . ,; ~rtain Drain ~pth: ~ <br /> <br />HEfl~t ~ ~ ~el: ~/~ ; Static Head in System: f~. <br /> ~ ~cle Time: ; ~11ons per <br /> <br /> I KEREBY CERTIFY TRAT THE ON-SITE SEWAOE <br />SYSTEM INSTAI22ZD AT THE ABOVE ADDRESS WAS CON- <br />STrUtTED ZN ACCO~A~C~ .Z~ TH~ ~ouzmmm~s oF <br />T~ P~P-~XT ~,~ T~ Ru~ss 0z ~ SNVZRON~NTAL <br />o_u~j~ CO~SSmN. <br />[&~" I have tested the septic tank and certify <br /> it to be watertight. <br /> <br />The syste~ ~as installed by: <br />[ ! ~erty Owner (pe~mitee) <br />[~"Licensed Sewage Disposal Service <br /> <br /> (please print) · <br /> <br /> (for Marion County USe only) <br /> County. The <br />~J The above septic system has been inspected by Marion information <br />H to be accurate and the system is: <br />~ [ ] Approved <br />~ [ ] Approved with corrections: see inspection report <br />~ [ ] Denied _/~./ ~ ~- <br /> <br />as-built, frm 4~95 WHIT~C~ar. mOg. i~'gunty; <br />MC-15-S41 ' ' :' ~:: <br /> <br />Date <br /> <br />::: ,de.re'mined <br /> <br /> <br />