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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 /� /8 /, /� <br /> ------. _ 503-588-5147 PERMIT NO. 5 J ` "coo 7 2 9 /✓�e� � <br /> MARION f (� <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection SITE ADDRESS: 5 6/-(9 /(tJeg©[Od 12.1 <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: Sa1 erVi, OR 9? 30 2- <br /> Scale: 1 — ,,�1 / <br /> 1 U CR-�1 I T <br /> North <br /> I <br /> KI. <br /> '''"'. V--":2. <br /> 'H0c.) S e <br /> A <br /> 4,.. <br /> - 8 ; 22 <br /> s <br /> 6- 15 f <br /> a <br /> s <br /> t <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 /> 1,aSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1000 total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: WA-I Tr' [ ] double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: (1.0 0 C k 4 e [ 1 flow-through I ] I have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer: Header Pipe: The system was installed by: <br /> Size/Mat'1 Size/Mat'l I I Property Owner(permittee) <br /> Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe I I Drop I I Concrete DEQ License Number: 3 8 p <br /> Pipe total depth I I I Distribution I I Plastic Q 3 7 <br /> DEQ Certification Number: '` <br /> Drainfield Material(Altemative or perf.pipe) <br /> Total Drainfleld Footage Trench Depth Minimum Maximum /� <br /> Curtain Drain Depth_ Signed:_ � <br /> Effluent Pump: Pump Model n/� / //����,,, ppl // / <br /> Pump cme �€ z t/ ,ft.e Cela(/'/L. C <br /> 7 <br /> times in minutes: on off Gallons per Cycle Company name: <br /> (please print) <br /> ATT Make and Model <br /> Attach an additional sheet for components and materials not listed above. Date: 7—/ / <br /> (For Marion Coun 1 se I lv) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: ' Ap. oved [ ] Approved with corrections: see inspection report [ I Denied <br /> AP.Signed: Title: Date: .c (I? <br /> MC:S-41 rev: +03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County;YELLOW:Owner;PINK.:Insialler <br />