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r <br /> '�. _ MARION COUNTY BUILDING INSPECTION <br /> 5155 Silverton Rd NE <br /> ---7'. ''''' SALEM OR 97305 . <br /> realpN INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> COUNTY (to be completed by system installer) <br /> SITE ADDRESS: 6 g.4416eyeek PERMIT NO. /F. 6 0 LZ4 v — t4 <br /> 111 r <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> IScale: 1"= T <br /> 1 North <br /> e &' 9�l ,v�/C 3c_ 4 <br /> I ' <br /> 7 ) , i C�l <br /> &C't 64 1 0 ke,9 ople rj_zi <br /> yr '%I <br /> p k h, "� <br /> l P f � <br /> r <br /> A -g ILS`' � '� . <br /> A -c, �e� A �l °c - g _ / cil <br /> \Avs' <br /> o <br /> FT. <br /> P P <br /> (� �-� � f�i' (sh,•w all details and dimensions necessary to locate all componen s of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: ` INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow: V-57, Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> % STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> Septic Tank:Size: IS Mat'! C.,lyt,G,,,o Mfg: k 60`\'C 5 . DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OOJHE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size: Mat'! Mfg: I have tested the septic tank and certify it to be watertight. <br /> Alternative Treatment Technology The system was installed by: <br /> / ^r�� I I Property Owner(permitee) <br /> Effluent Sewer:Size: Mat'!: ptie,„ Licensed Sewage Disposal Service �" <br /> Box(es): Distribution; I I Drop / I�Concrete; I I Plastic DEQ License Number: 9 d <br /> Drainfield Pipe:Size: V rl;Material:Header: LP i <br /> JII ;Pcrf: vI/c., DEQ Certification Number: LZ4® <br /> Total Drainfield Footage: Sem :Rock Depth: <br /> Total: ;Under Pipe: +'� <br /> t q Signed:_ c* <br /> Alternative Drainfield Materials: 62 f}�•'tO .) <br /> Trench Depth:Minimum: / :Maximum: d <br /> SO ;Curtain Drain Depth:_ 4/Z Company name: tet wt). /,./1: <br /> (please print) <br /> Effluent Pump:Pump Model:f7P 3b :Static Head in System /0 Ft. !/ <br /> Date: <br /> Pump Cycle Time: :Gallons per Cycle: <br /> Attach an additional sheet for components and materials not listed above. <br /> (For Marion County Use Only) <br /> The above septic system has • =n inspected b, Marion County.The information has been determined to be accurate and the system is: <br /> il>dazproved <br /> I I Approved with cor ctions: see i•- ection report <br /> I Denied <br /> Signed: / Title. : Date: Slig b <br /> MC: S-41 rev: 3/03;4/12 WHITE:Marion County; YELLOW:Owner; PINK.•Installer <br />