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gitoMARION 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 /> MAIiIQQN 503-588-5147 PERMIT NO. 15-5-- (1 -O 00 01 9 <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 14.$ 2-2-- FiatN /2606 <br /> £ /lUAD SL <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: SMYMAI <br /> Scale: 1"= T <br /> 'Borth <br /> re)6a �c�,r-��-� <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 /> Design Sewage Flow y ft, Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: O (d total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> 7.- [ ] double compartment OF THE ENVIRONMENTAL QUALITY_JMMISSION. <br /> Manufacturer: A1., Tic ccost e <br /> Material: G'eir/C.itQyc [)4 flow-through I I I have tested the septic tank a;,_certify it to be watertight. <br /> Effluent Sewer: , Header Pipe: The system was installed by: <br /> Size/Mat'1 11 r 3 O 3 ci Size/Mat'l Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe 6 r 13)Drop I I Concrete DEQ License Number: <br /> Pipe total depth /.i'1 I I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Alternative or perf.pipe) PA f f /P - y <br /> e 1 <br /> ,. 1 I, Il <br /> Total Drainfleld Footage 1/0 0 Trench Depth Minimum ay Maximums <br /> Curtain Drain Depth Signed 4e l/• `,/e..�fi l <br /> Effluent Pump: Pump Model <br /> Pump cycle <br /> times in minutes: on off Gallons per Cycle Company name: _- <br /> (please print) <br /> ATT Make and Model ---- q <br /> Attach an additional sheet . components a materials not listed above. Date: 4' ¢/ u / / / <br /> (For Marion Coun VS nlv) e above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system i�♦ • i rov [ I Approved with corrections: see inspection report [ ]Denied <br /> _OKl.• Title: Date: � i I 9 <br /> MC:S-41 r• 3/03;4/12;5/14; 11/17 G:\Forms\Septic\S-41 As-Bui!t2015Version2017.doc WHITE:Marion County; YELLOWOwner;PINK:Installer <br />