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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 /> --o.=` - SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. s s S— I g —006 17 1 - PR/17-- <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspectiont1i-�' �(' <br /> SITE ADDRESS: •�0 i 7 '01.. ,�Gc M e G/[/ 5,-,.-_,S, ic_n_t <br /> gR. S 61 t GA.-h.3 4 SA,le, oP <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= kg' k/L. / T <br /> a — <br /> _ North <br /> • � 1 e - G - )Zo'G /. <br /> ` ,Mr I. <br /> i VII 4 i1"'- <br /> - I <br /> .-.001111111 <br /> ® bra <br /> 1 3 )lilh ,, K <br /> c v c ® \ <br /> ti I c <br /> iTC4 I <br /> Z? • d c , <br /> w �� `.: <br /> ' <br /> 0.I - _ <br /> 420 <br /> (show all details and dimensions necessary to locat;all c., ponents of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> System Design Sewage Flow L(K O 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 ])ooU gallons Mat'I 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 Box(es): <br /> l� [ ]Distribution The system was installed by: <br /> Effluent Sewer:Size 1 Mat'1 30 3I/ Drop <br /> I ]Property Owner(permittee) <br /> tt ][ Concrete Licensed Sewage Disposal Service <br /> Drainfield Pipe:Size' / [ ]Plastic <br /> Material:Header Pipe Iv 3 Li Perforated Pipe DEQ License Number: 3 i 15 if <br /> Total Drainfield Footage LI6O Trench Depth Minimum 211 Maximum_21 DEQ Certification Number: -I= 2/3 L1 <br /> Rock Depth:Total Under Pipe Curtain Drain Depth � <br /> n Signed:_ e, <br /> Alternative Drainfield Materials I—2 -0-i d L✓ J <br /> Effluent Pump: Pump Model Company name: (?J)t ei( �f-ce /s�'i.-//v' , <br /> Pump Cycle minutes minutes (please print) <br /> Time on off Gallons per Cycle / <br /> Attach an additional sheet'for components and materials not listed above. Date: [1 6//1 <br /> (For Marion Coun use I nlv) <br /> The above septic s em has teen inspected by Marion County.The information has been determined to be accurate and the system is: <br /> [`A Approved / [ • pproved with corrections:see ins•ec,'on report [ ] Denied <br /> Signed: Ai _ - Title: / ` Date: '7 1U VP <br /> MC:S-41 rev:3/03;4/12•`/14 WHITE:Marion County;Y LLOW:Owner;PINK:Installer <br />