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i <br /> ,ul ''eau <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> r�� 5155 Silverton RI)NE <br /> arm Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marlon.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: } ,t' <br /> SITE ADDRESS: L('1q(e te Le- el— ,vo 0 I. 10 T o Z— <br /> DATE: 12. J/1411 j <br /> FILE NUMBER: aa--0 I O\fl \C i <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): g v.4.1 0 (e, <br /> Company Name: <br /> Mailing Address: . <br /> VrriN i 0 '' TWO7_. <br /> Phone Number: J5i2 3) 2 '7 3 <br /> G.\FORMS\SEPTICIS-38 RR Certific tianFirtal.doc S-38 Rev: 9/10,1/11 <br /> 60/90 3E17d 0880186E0S Lb:6L ET06/bi/L0 <br />