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3150 Lancasler Dr NE - Suite C <br />Salem, Oregon 97305-1398 <br /> <br />Pltg 588-5147 <br />FAX//588-7948 <br /> <br />PROPERTY OWNER: <br /> <br />SITE ADDRESS: <br /> <br />SITE NUMBER: <br /> <br />SEPTIC SYSTEM CERTIFICATION <br /> <br />I, hereby, certify that the attached site plan is an accurate representation of the conditions on <br />my property, and that.the proposed structure meets all minimum setback requirements from the <br />existing septic system, and the future septic system replacement area. <br /> <br />I further certify that I have, to the ~st of my abilities, thoroughly inspected the septic system <br />and found no evidence of any faille.,/~he s~ystem appears to be functioning in a satisfactory <br />manner at this time. <br /> <br />SIGNATURE: ~ gV~-~ : / <br /> oi -rty o ner aathor ed a ent <br /> <br />Name (please print): <br /> <br /> / <br /> <br /> <br />