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INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> - (to be completed by system installer) <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />scale: 1" = ' % <br /> North <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 /> size: OOO Mt'l: CO C. Mfg: <br /> <br />~S~ T~: Size: ~ ~t'l: ~ Mfg: <br /> <br />~(eS), ~Distribution; ~] Drop / ~ Concrete; [ ] Plastic <br /> <br />Dza~fteld Pipe: Size: r: ; Perf: <br /> <br />TO~I Drm~nf~eld F~tmge~; ~ck ~, Total:--; ~der <br /> <br />lffl~t ~: ~mp M~el: ~ ; Static Head in System: --ft. <br /> <br /> ~mp ~cle Time: ; Gallo~ per ~cle: -- <br /> <br /> INSTALLerS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE <br />SYSTEM INSTALLED AT THE ABOVE ADDRESS WAS CON- <br />STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br />THE PERMIT AND T~E RULES OF THE ENVIRONMENTAL <br />QUALITY CO~4ISSION. <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 /> (for Marion County use only) <br /> above septic system has been inspected by Marion County. The information has been determined <br />~be accurate and the system is: <br /> Approved <br /> Approved_~ith correct~ons:~ see inspection report <br /> <br /> Title: Date: <br /> f WHITE:Marion County; YELLOW:Owner; PINK:Installer <br /> <br /> <br />