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'.• ittlf&p„ .MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> i .......---z..-..:......,-.....--..,. .-,-,-..••••‘,. _..,., 5155 Silverton RD NE <br /> 1..„-.-...,...-...„„,,..„...-z „. <br /> Salem OR 97305 <br /> . (503)588-5147 F'ax(503),-5884948 <br /> http://www„CaMarion.orms <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: c,.. ,c4„.. +1.7" IA:f7c(- J! <br /> L k ' <br /> srrE,ADDRESS: . ,' 64.c ‹yi fik . , d. iLl IA, <br /> )I Lt 5C t,0' iji C't L IV ,E to lb - oviioli <br /> . <br /> qiir ,,,i <br /> DATE: i fi-2.:.'-1 <br /> OlOn - 6 -'9 5 &E <br /> LE NUMBER: 211 5 P <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, inciuding 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 aseptic system. <br /> I further certify that I have,to.the best of rny abilities,thoroughly inspected the septic system and found <br /> no evidence of any failure. The system appears to be functioning in-a satisfactoty manner at this time. <br /> SIGNATURE: <br /> , <br /> (Property Owner or the.Owner's.Authorized Agent) <br /> det..4.„.. <br /> Name(Please Print): L.c. ea ( Ictikb-c‘f <br /> Company Name: <br /> n , <br /> Mailing Address: 1\ ti <br /> t f <br /> Vio.cut,v. 6 IS, 9767) <br /> rk <br /> Phone Number: <br /> GAFORMS‘SEPTIPS-38 RR CertificationFinal.doc S-38 Rev: 91I0;1/1 1 <br />