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*0;1MARION COUNTY PUBLIC WORKS 1 -60 AC <br /> ,,,,,,� r 7.3,5 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton RD NE D5 {E [F3 I W/ E <br /> Salem OR 97305 J L <br /> (503) 588-5147 Fax(503) 588-7948 "1 —JJ <br /> �!�',' 0 7 to f <br /> http://www.co.marion.or.us <br /> • MARION COUNTY <br /> BUILDING INSPECTION <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: ck \ 5 *rot cv r <br /> SHE ADDRESS: 1 `i ? O '4 y < u rrer Q,-- ? 75 9 <br /> DATE: 5 fl 9 <br /> FILE NUMBER: <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: okJY4)°--(111) - <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name (please print): Ra, (\kI $ +r4 w r <br /> Company Name: <br /> Mailing Address: <br /> Phone Number: ci 7 / 'ZS y_ 3 6 74 <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />