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MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> �_ 5155 Silverton Rd NE (to be completed by system installer) <br /> --, �3 SALEM OR 97305 <br /> 503-588-5147 PERMIT NO....c SS- 18-00 3 2 Li Li <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: '5J- <br /> n�GrGS 1.1 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: 212 `�c-fN t v.1 N 5 <br /> Scale: 1"= o ' i; T <br /> L <br /> North <br /> N5 <br /> • / lam . A_ — 1 ; 1 7t� a <br /> `' ,b <br /> ,sot fiT� ;V -- _ vi g — o - 36 i 3- <br /> is (, r `io -c, <br /> U i <br /> iO®. — <br /> A 7,.I I tow&.a co r. Li h-C— z� <br /> s ow all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> �'�SC7 Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANKSize: I� t D C total gallons [``]single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: me., <br /> 46-S. <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: L.orierf.4t [A flow-through [ I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pi e: The system was installed by: <br /> P " <br /> Size/Mat'1 y" 3,0 34/ Size/Mat'l 1•1 7o7y I IProperty Owner(permittee) <br /> [ I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe [4 Drop 19 Concrete DEQ License Number: 3 Go o Q <br /> Pipe total depth I I Distribution I I Plastic <br /> p DEQ Certification Number: _r 2 1 3y <br /> 1 <br /> Drainfield Material(Alternative or perf.pipe) �i 1 tlo U <br /> Total Drainfield Footage ISC,) Trench Depth Minimum2 Maximum_ zy <br /> Curtain Drain Depth Signed:_ a ® <br /> Effluent Pump: Pump Model . <br /> Pump cycle 1 <br /> times in minutes: on off - Gallons per Cycle Company name:_ Qe -G/ Cif c c.Ci,erli h <br /> (please print) <br /> ATT Make and Model 7- 3/ <br /> Attach an additional sheet for com••• : • aterials not listed above. Date: 2• <br /> (For Marion Count , .e Only) The..ove septic ystem has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: i. -,; ,v'ed [ I Approved with corrections: see inspection report [ ]Denied • <br /> Sign;..; <br /> - - ..Title: 3 Date: Of IC/ <br /> MC:S-41 rev:-/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YFrLLOW::O ner;PINK:Installer <br />