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MARION COUNTY PUBLIC WORKS <br /> 'di NM?' BUILDING INSPECTION DIVISION <br /> i 5155 Silverton RD NE • <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us <br /> • <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: \ <br /> SITE ADDRESS: 2 124/6 (/- i uok cc-7"8-5 i 115 q7 3 '7 <br /> DATE: V-2e '2-3 <br /> FILE NUMBER: 23 r Q01 —ft& <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 /> _ �t <br /> SIGNATURE: \ 9�' �` <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name(please print): Pt-I`e't- 60,IA vk v <br /> Company Name:Mailing Address: 2. (2 Lj 6 A-b i ce IA" Iv e. / 3 e-v 445 e-t- i I Is , 973 75- <br /> Phone Number: S—v 3 ` c(5^ ` 3 6y <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />