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"� MARION COUNTY PUBLIC WORKS <br /> di! 1jt�1%* BUILDING INSPECTION DIVISION <br /> ""7 5155 5155 Silverton RD NE <br /> ' Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: CL N\65 M l VO <br /> SITE ADDRESS: 2 C) 3 'y F 'ci c ?kc V1e Y(,'\ J1(� S� v/ •71 3 <br /> DATE: 12 2_? 7 3 <br /> FILE NUMBER:355- V IO3S <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 /> (Pr perry Owner or the O er's Authorized Agent) <br /> Name(please print): <br /> Company Name: <br /> Mailing Address: <br /> Phone Number: <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />