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MARION COUNTY PUBLIC WORKS D {J n <br /> BUILDING INSPECTION DIVISION V <br /> ECE <br /> 5155 Silverton RD NE <br /> Salem OR 97305 JUL 1 0 2023 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us MiARION COUNTY <br /> 3UILDING INSPECTION <br /> S-A-D \C <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> • <br /> PROPERTY OWNER: a-rp't d -cc)t <br /> SITE ADDRESS: I J 7, 7 Tr I,U w4 -R. SE . Scc,11'svi. <br /> DATE: 7 /07Z 0 Z J <br /> FILE NUMBER: 3 -005 O; -0os 8 t (- )C <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 structure(s) 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 /> SIGNATURE: <br /> �/rr pertly Owner or the er's Authorized Agent) <br /> - Name (please print): /- 1 7— • <br /> Company Name: K fpc,5 • <br /> g T. 0 . �0K 2C. ( 1 `ti-e , O6�' c173z5 <br /> Mailin Address: w�"'(S'�i <br /> Phone Number: 52 3 - Yoo-lzg/ <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />