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Marion Coqn ty <br /> <br /> OREGON <br />COMMI3N[TY DEVELOPMI~N¥ <br />DEPARTMENT <br /> <br />SEPTIC SYSTEM CERTIFICATION <br /> <br />PROPERTY OWNER: <br /> <br />SiTE ADDRESS: <br /> <br />SITE NUMBER: <br /> <br />PERMIT NUMBER: <br /> <br />I, hereby, certify that the attached site plan is an accurate <br />representation of the conditions on my property, and that the <br />proposed structure meets all minimum setback requirements from <br />the existing septic system, and the future septic system replace- <br />ment area. <br /> <br />I further certify that I have, to the best of my abilities, <br />thoroughly inspected the septic system and found no evidence of <br />any failure. The system appears to be functioning in a satisfac- <br />tory manner at this time. <br /> <br />SIGNATUI~E: <br /> <br />Name (please print): <br />Mailing Address: <br /> <br />(property owner or authorized agent) <br /> <br />MC15-S38 <br />Rev 2/93 <br /> <br />24 Hour Code-A-Phone $8~7904 <br /> <br />(503) 588-5147 Senator gui[ding <br />~AX(503) $88-7948 220High <br /> <br /> <br />