Laserfiche WebLink
O IJie. <br /> NN,. N 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 /> MARION 503-588-5147 PERMIT NO. J "[D r 7 <br /> COUNTY http://www.co.marion.onus/PW/BuildinglnspectionU Y � --� , <br /> SITE ADDRESS:(. C1C1 14 Ka (i, ^ , I c ee <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: . <br /> Scale: 1"_ ' 3 , c \a T <br /> cs <br /> \ ,�-t; �0, rth <br /> �t✓Q it..... ` . <br /> \` \Ib <br /> • l 0 N <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: /O <br /> M total gallons single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: [ ] flow-through XI have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer It Header Pipe:,tl The system was installed by: <br /> Size/Mat'l Size/Mat'l J 4 7 I I Property Owner(permittee) <br /> 'Licensed Sewage Disposal Service <br /> DRAINFIELD rock depth(fiches) Box(es) <br /> ock and under pipe // [ l Drop /Concrete DEQ License Number: 33(20 <br /> • Pipe total depth distribution I I Plastic ^� <br /> DEQ Certification Number: ,,F 5 '? <br /> Drainfield Material(Alternative or pert.pipe) • <br /> I // <br /> Total Drainfield Footage <br /> Trench Depth Minimun0 Maximum I , .,„__ <br /> Curtain Drain Depth_ no Signed: `/ - . <br /> _. <br /> Effluent Pump: Pump Model 1)111 . <br /> Pump cme ,/1 9'e . •�y� <br /> times in minutes: on � off �� Gallons per Cycle `"� Company name:_''/J( '� t <br /> ATT Make and Model �� (please pn t) . <br /> Attach an additional sheet for components and materials not listed above. Date: _ <br /> (For Marion Comity Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> andthe system is: Ti47 Approved [ ] Approved with corrections: see inspection report [ ]Denied <br /> Signed: (.:%44' fsL 1c. ,Q €, th-j2 EH S TitleO/[ WariZakii9t, Sea Date�t[. Z-42J, I <br /> MC:S-41 revr3/03;4/12;5/14;11/17 G:\Forms\Septic\S-41 As-Built2015Version2017.doc WHITE:Marion County; ELLOW.•Owner;PINK:Installer <br />