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Nw MARION 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. j )�' 'C✓r j y j <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection % c"� <br /> SITE ADDRESS: t •.�,��%' �,�-' A,,,/ <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"=T.5 _' `T <br /> Ai North <br /> N\ <br /> I <br /> 11; , y <br /> A-3' t"' # ......� <br /> h . <br /> ... <br /> (show all details and dimensions necessary to locate all components of the s j'stem in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I� I HEREBY CERTIFY THAT THE dN-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow "9 5 O Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: i ed C total gallons • [)Q single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> n double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer: .11V 4"..;p [ ] P <br /> Material: (J r1C.)/-4- [ ] flow-through I I I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewe :, .t Header Pipe: '1 if The system was installed by: <br /> Size/Mat'1 11 d 3c " s� Size/Mat'l vI 3O —3 Li I I Property Owner(permittee) • <br /> I I Licensed Sewage Disposal Service ,v, <br /> DRAINFIELD rock depth(inches) Box(es) , -- v.,? , �, ��_� <br /> Rock and under pipe I I Drop A Concrete <br /> DEQ License Number: <br /> Pipe total depth VI Distribution I I PlasticB <br /> a DEQ Certification Number: 'I 19 S5 <br /> Drainfield Material(Alternative or perf.pipe) lvUI <br /> Total Drainfield Footage 9,00 Trench Depth Minimum 1 3 Maximum <br /> Curtain Drain Depth_ Signed:_ .deC ..t.h c , <br /> Effluent Pump: Pump Model . <br /> Pump cycle ,` / <br /> times in minutes: on off Gallons per Cycle Company name:_J V CAA) if%)1(_ (-,ci,�,, iciit <br /> ATT Make and Model 3 (please_ print) <br /> Attach an additional sheet for components and materials not listed above. Date: 14— B ) 1<1 <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: RApproved [ ] Approved with corrections: see inspection report [ ] Denied <br /> /. l7✓LtS,°fit— cOa-8#�.--� . - /I a <br /> Signed: Las,„ ' i if e: A) '' m ':J � Date:j//IMS 7'2 l 1 <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;Y GLOW.:Owner;PINK.•Installer <br />