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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. ,5,S— I °� — CV2-3 iv 7 <br /> MARION <br /> COUNTY http://www.co.marion.onus/PW/Buildinglnspection <br /> SITE ADDRESS: 37 7' w......c. ..11p 1.,/t` 52 ijin.a <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"__' X <br /> North <br /> I J$ r <br /> 010 Ire <br /> iv <br /> tit ---7 <br /> _ -a' 1" <br /> R �'� J.., <br /> 1 g.' , ra <br /> tP <br /> 8 <br /> J ems, <br /> r \\11. <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 /> Design Sewage Flow Gallons/Day I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> SystemSTALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: 1 ,' 0 0 total gallons ix single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Manufacturer:Walla [ ] doublecompartment <br /> Material: ettlA f [ ] flow-through 1 1 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'l 44/11;40...9 27191x234/ Size/Mat'l ly'�Q7 Zg I 1 Property Owner(permittee) <br /> I I Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) r� <br /> Rock and under pipe ‘ "r I I Drop I J Concrete DEQ License Number: J-7490 <br /> Pipe total depth 12. 4- I istribution I I Plastic ,�IGvr <br /> DEQ Certification Number: - <br /> Drainfield Material(Alternative or perf.pipe) p.�>P <br /> Total Drainfield Footage 3,200Trench Depth Minimum).y Maximum.Piofi It <br /> to .LJ../�)�1 <br /> Curtain Drain Depth Signed:4SV yrCJ <br /> Effluent Pump: Pump Model . <br /> Pump cycle o <br /> 4411-67C....5times in minutes: on off Gallons per Cycle Company name:_'Elle A. <br /> ATT Make and Model (le .L !ase print) <br /> Attach an additional sheet for components and materials not listed above. Date: <br /> (For Marion Cou r Use Onl ) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is•"01/ppri ed [ ] Approved with corrections: see inspection report [ ] Denied <br /> Z3 <br /> Signe. '� Title: Date:MC:S-41 rev /03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built20 Version2017.doc WHITE:Marion County;YE LOW.:Ojici <br /> ner;PINK:Installer <br />