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r <br /> ��MMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> ""••'--- 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> •"-^—. 503-588-5147 • PERMIT NO. /9"--(9603 V 7 Pont-- 0 1 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildinglnspectionSITE ADDRESS: Z‹ 1LUrl'e?YS'd!'I ,,,gCt � vn <br /> • r. <br /> ry. <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: `'!e cre V ST9 PI er. '?731 p-- <br /> Scale: 1"= no-i' %"t7 _5 LQ 1 e T <br /> North <br /> • <br /> 5'I <br /> • <br /> \� I` <br /> • <br /> tafu 7-1-1 <br /> 4e % Vu <br /> 1 X19' . <br /> 1, V< <br /> . in ) x <br /> a 0, <br /> . ,st. . - , mco . . <br /> ca • . vs . <br /> , .5-ekt, <br /> • . <br /> v. <br /> "NO S-�i e- v % r <br /> • <br /> . V <br /> • <br /> • <br /> . <br /> EXLS� iv`7 `110�S. ' <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> /� <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow / •AMallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> , TANK Size: rat -•- total gallons ' [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> rO [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer:,E',44, ,A t 1 T 1r'� ' <br /> �y'G1 <br /> \ [ ] flow-through IXI I have tested the septic tank and certify it to be watertight. <br /> Material: Po l).- �f�S� <br /> Effluent Sewer Header Pi e: The system was installed by: <br /> „ P <br /> Size/Mat'I 4 .SD R ..S Size/Mat'l Property Owner(permittee) • <br /> I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) . <br /> Rock and under pipe ,{3iQ Drop ] ]Concrete •DEQ License Number: <br /> Pipe total depth {Distribution Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) <br /> • <br /> Total Drainfield Footage Trench Depth Minimum Maximum <br /> Curtain Drain Depth_ Signed:_ 4 i,c¢...a ij Qh ' • <br /> Effluent Pump: Pump Model <br /> Pump cycle � ^� <br /> times in minutes: on off Gallons per Cycle Company name:_ V tlret l9 W lel e <br /> ATT Make and Model (please print) <br /> Attach an additional sheet fo mponents and materials not listed above. Date: <br /> (For Marion Coun,• Use •nlv) The ove septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: • _• 'proved [ I Approved with co�tzct}'ons: see inspection report [ ] Denied <br /> Signed: , . a:/ Title: Date: <br /> MC:S-41 rev:343;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELL W::O ner; INK:Installer <br />