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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION IECVIVEI-n)5155 Silverton RD NE <br /> 11111 <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 AUG 11 1.O7 <br /> http://www.co.marion.or.us MARION COUNTY <br /> BUILDING INSPECTION <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: Ro6g7L ,�� ' I Coi c/( <br /> SITE ADDRESS: 683 5 r 707Y-1 Ave S�/ �/' ` 7Y/ 7 <br /> l <br /> DA1I : g-7— 2023 <br /> FILE NUMBER: C — nOl2W121167E <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 /> (Property Owner or the Owner's Authorized Agent) <br /> Name(please print): ff,f4.ert/C: i4G:A(Ji?P <br /> Company Name: Z/1,v271ei' /'e -k S71-a,‘l- S <br /> Mailing Address: 19g3 S' 707z4 Ave._ <br /> s.ei,L 0/, 97 ?/ <br /> Phone Number: Gj 41l IF 91 - 41.22 7 <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />