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.gli �''� IkLARION COUNTY PUBLIC WORKS <br /> T" BUILDING INSPECTION DIVISION <br /> 17.'% �`1 5155 Silverton RD NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax (503) 588-7948 <br /> http://www.eo.marion.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: Led Ash <br /> SITE ADDRESS: ` 90 9 . ,Sci'rc k A\ 'Tt�f , c c erecn, 913°LP <br /> DATE: / <br /> FILE NUMBER: <br /> I certify that I have personally investigated the existing septic system on the above property and have <br /> identified the exact ocation of all parts of the septic system. including the septic tank, distribution box <br /> or drop boxes, drairfield lines and future septic system replacement area. The attached site plan is an <br /> accurate representat on of the location of the septic system and proposed structure(s) on the property, <br /> and the proposed c evelopment meets all minimum setback requirements from the existing septic <br /> system, and the futu.e 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 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 /> ro rtv wner or the Owner's Authorized Agent) <br /> Name (please print): 1 -A`<6�• L Z,, , <br /> Company Name: shp \ atik.s e <br /> Mailing Address: Q_)•` Q)C b .A5'\ <br /> _ e{> cae G\ 1 oa3 <br /> Phone Number: <br /> G:'.FORMS\SEPTIC\S-38 RR :ertiticationFinal.doe S-38 Rev 9/10,1:11 <br />