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,a ,,,,,� MARION COUNTY PUBLIC'�'4`ORKS <br /> "" BUILDING INSPECTION DIVISION <br /> 5I55 Salzertan RI) NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax (503)588-7948 <br /> http://www.coiniariottiorius <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PR()Pl kTY OWNER: &us.t e ` ca r r�tt <br /> SITE ADDRESS: i V1 PR,cl .._ <br /> F �NIBER: ..r e? g !1 <br /> t L1-t,lvl.�l ,✓' '..� <br /> I certify that I have personally investigated the existing septic system on the above property and have <br /> identified the exact location of all parts of the septic system, including the septic tank, distribution box <br /> or drop boxes, drainfield lines and future septic system replacement area. The attached site plan is an <br /> accurate representation of the location of the septic system and proposed structures) on the property, <br /> and the proposed development meets all minimum setback requirements from the existing septic <br /> system, and the future septic system replacement area. In addition if there isn't a septic system serving <br /> the property, this document is to certify that a full investigation has been made to determine that the <br /> parcel is not being served by a septic system. <br /> I further certify that I have,to the best of my abilities, thoroughly inspected the septic system and found <br /> no evidence of an, failure. The system appears to be functioning in a satisfactory manner at this time. <br /> SIGNATURE: <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name(please print): 1 cii_ii•( N\ $-o r cr a • <br /> Company Name: <br /> MailingAddress: (6 <br /> � 3 ��rq�n �d- rt t< <br /> 11 <br /> j <br /> Phone Number: 6 l g.G348 <br /> 0\FORMS\SEPTICAS-38 RR CertificationFinal.doc 5=38 <br />