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,ilk,�� ` MARION COUNTY PUBLIC WORKS <br /> 1 BUILDING INSPECTION DIVISION <br /> 5155 Silverton RD NE I'I' <br /> . Salem OR 97305 11 JAN 25 291g 1=1 <br /> 1111111 <br /> (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.usI, ; r <br /> , � , <br /> • 1 <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: t'11 ci net Vs4$- l S c ,.,�� ; <br /> SITE ADDRESS: 11 11 4 ¶: ' "i cru NiE aa-913.31 <br /> DATE: 1 1.2, 1 <br /> FILE NUMBER: )55 (1-0013 L tiq -1-K10`( <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 /> roperty Owner or t .- •wner Wi tho Agent) <br /> Name(please print): ctan �Qfc.kve(- / krt+5+4 I Spi-,cc e <br /> Company Name: <br /> Mailing Address: MT :;1( Lii C <br /> S\►\ve 4on t Z vi3g1 <br /> Phone Number: cj b?) - 15 3 C <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />