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`kz^ MARION COUNTY PUBLIC WORKS <br /> AI 1j1ji,,,n_® BUILDING INSPECTION DIVISION <br /> �/�`��e1I 5155 Silverton RD NE <br /> `_ , - Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> f 1 lc— <br /> PROPERTY <br /> OWNER _ `�`kr E iJ 2VV e .--t" i .__ <br /> SITE ADDRESS: ' 0 l ps°p-PtrvL )� <br /> DATE: \ 1 4 ' 12i27 � � <br /> - n0Ar- 0f2_ <br /> . ---7 <br /> FILE NUMBER: 2 - (0s-7 G l i E G 39 2- <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 any failure. The system appears to be functioning in a satisfactory manner at this time. <br /> SIGNATUI <br /> ope 0 r or the Owner's: uthorized Agent) <br /> Name(please print):. <br /> Company Name: <br /> Mailing Address: j D r----a <br /> d 75. <br /> - ,ram_ C) Cit 13°!? <br /> Phone Number 6 D :..:: Ct 3 0 I 4 Co <br /> G:1 FORMS 1SEPTICIS-38 RR CertifcationFinal.doc 5-38 Rev: 9/10,1/11 <br />