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. MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> F 5155 Silverton Rd NE (to be completed by system installer) • <br /> - °'" -:: Salem,OR 97305I <br /> 503-588-5147 PERMIT NO. SS k— 00`-k9 7 <br /> •MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection 10 5 � J�q(4rd C± <br /> SITE ADDRESS: <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: • �� r0 <br /> Scale: 1"=i.irc T' <br /> North <br /> ) ]I® <br /> P o 47 L <br /> , <br /> —v /-1°,1e4 <br /> 0. c>. (ri... 1 7.14 <br /> m got <br /> (rail - 114 0 <br /> yiw '-rr <br /> t <br /> i3'^ ws s. °' <br /> Pa.'a/ r. <br /> 4 <br /> d-` <br /> c . <br /> (show all details and dimensions necessary to locate all components of the system in the future) Prop . il.,p, ' <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow L/50 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 Il C)O 0 gallons.Mat'I gt71.f}'f`. Mfg III efiffrehtir DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Dosing Tank:Size gallons Mat'I Mfg <br /> xiI have tested the septic tank and certify it to be watertight. <br /> ATT Make and Model Box(es): <br /> �P I I Distribution The system was installed by: • <br /> Effluent Sewer:Size L7 Mat'I P V— DWV Sok'{® I I Drop 'Property Owner(permittee) <br /> " Concrete I I Licensed Sewage Disposal Service <br /> Drainfleld Pipe:Size l l Plastic <br /> r <br /> Material:Header Piper 0-ry Perforated Pipe_ DEQ License Number: <br /> Total Drainfield Footage 13 0 Trench Depth Minimum .!/ Maximum 1Y DEQ Certification Number: <br /> Rock Depth:Total Under Pipe Curtain Drain Depth_ <br /> Signed:_ PI c---7-a— <br /> Alternative Drainfleld Materials L Z ow 12 o 1 <br /> • <br /> • <br /> Effluent Pump: PumpModel <br /> p Company name:_ <br /> Pump Cycle minutes minutes (please print) • <br /> Time on off Gallons per Cycle / �y <br /> Attach an additional sheet for components and materials not listed above. _ Date: —` If CJ <br /> (For Marion County Use Only) <br /> The above septic system has been inspected by Marion County.The information has been determined to be accurate and the system is: <br /> [?j Approved,. n [ ]Approved with corrections: see inspection report I ] Denied <br /> Si.:, . ate., 2. / � <br /> :f: G/ Title: 0i1ae (4) D 'lUINI&-m- coy W($ <br /> MC:S-41 rev:3/03;4/12;5/14 ,Q.p.e,t j <br />