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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 /> '"'%-•. .- SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. l (CYb i`<,G <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection <br /> SITE ADDRESS: 7 G( 1 C, D D Y q C.14 1-114 <br /> A" cS°A-L r A/S <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= ' kte, N I f <br /> • t) --a--.' 5;1 North <br /> CY <br /> 4/' <br /> \/ N 1 <br /> ,,,,9 V ___.----- _ _ _,_________. ___ <br /> ( F._.7.7 L--------------- - - 1 Lic,..-LAD 5 e----e'rkc--- —7-‘6,4-1 i< <br /> 1, . (::-.3c-1 cs 1 S , 11 <br /> ,t,1.\,;CI.4�I J� ..%,/t <br /> It rsi <br /> )It -------.1- 11C wAr `i <br /> r <br />, .1 _S '-.)..'1, ___, j_ L____...... <br /> \-\C.... ---4_. ,,,,,_..,.,.3_,__(;- <br /> \ ........__ pa.‘,1-6,20P--1c KI 04_1.14 <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 /> System Design Sewage Flow 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 1 LIM gallons Mat'l Mfg DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size gallons Mat'1 Mfg <br /> [ ] I have tested the septic tank and certify it to be watertight. <br /> ATT Make and Model 1 all-CS.... Box(es): <br /> [ ]Distribution The system was installed by: <br /> Effluent Sewer:Size Mafl ] ]Drop [ :f Property Owner(permittee) <br /> [ ]Concrete <br /> [ ]Plastic <br /> I I Licensed Sewage Disposal ServiceDrainfield Pipe:Size <br /> Material:Header Pipe Perforated Pipe i DEQLicense Number: <br /> - 2 <br /> Total Drainfield FootageTrench Depth Minimum Maximum\ DE Certification Number: <br /> Rock Depth:Total Under Pipe Curtain Drain Depth � _`_ Iy „ <br /> Si -e-1:17-- av'w .�'v'�---- ___, <br /> Alternative Drainfield Materials <br /> Effluent Pump: Pump Model • Company name:_ <br /> Pump Cycle minutes minutes (please print) <br /> Time on off Gallons per Cycle <br /> Attach an additional sheet•for compon•. .nd materials not listed above. Date: <br /> (For Marion Co . Use On' ) <br /> The above septi ystem has b-- inspected by Marion County.The information has been determined to be accurate and the system is: <br /> ,` Approved • pproved with corrections: see inspection report [ I Denied <br /> �% e/ <br /> Sign-_ • % Title: ��� Date: 42- <br /> MC:S-41 rev:3/03.•/12;5/14 WHITE:Marion County;YELLOW.•Owner;PINK:Installer <br />