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INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> <br />SITE ADDRESS: S358 Silver Falls Hwy SE ; PERMIT NO. 9B-03143 <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> <br />scale: il" = 50 , <br /> North <br /> <br />Silver Falls Hwy <br /> <br />(show all details and dimensions necessary to locate all components of the system in the future) <br /> <br />~si~T~nk, Size: 500 <br /> <br />E££1uent sewer: Size: <br /> <br />B~x(as): [ ] Distribution; <br /> <br />Dra~nffe14 Pipe: Size: <br /> <br /> Mat' 1: Concret~fg: Waite <br /> <br /> Mat'l: <br /> <br />[ ~ Drop / ~] Concrete; [ ] Plastic <br /> <br /> ; Material: Header: ~7~ ; Peri:__ <br /> <br /> .IDEil~r~tor <br />rot.l m=.*n~*el4 roote~e, E57 ;Rocm veptn~ Total: ; Under pipe: <br /> <br />Tr~ Depth: Minimum: ~4 ; Maximum: ~4,, ; Curtain Drain Depth: <br /> <br />~ffl~emt ~: Pump Model: OSI 10 ; static Head in System: l~ ft. <br /> <br /> Pump Cycle Time: S~i~ ; Gallons per Cycle: 90 <br /> <br /> IN$?~tm~$ CERTIFICATION~ <br /> I HEREBY CERTIFY T~AT THE ON-SITE SEWAGE <br />SYSTF24 INSTA~.tRO AT THE ABOVE ADDRESS WAS CON- <br />STRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF <br />THE PERMIT AND THE RULES OF THE ENVIRONMENTAL <br />QUALI~"f CO~XSSION. <br />[ ] I have tested the septic tank and certify <br /> it to be watertight. <br /> <br />The sltstem was <br />[ ]Property, <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 />[ ] Denied <br /> <br />Signed: Title: Date: -- <br /> <br />WHITE:Marion County; <br /> <br />YELLOW:Owner; <br /> <br />PINK:Installer <br /> <br />~s-built.frm 4/95 <br />MC-15-S41 <br /> <br /> <br />