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t`���, MARION COUNTY PUBLIC WORKS <br /> ��� 1�����''' BUILDING INSPECTION DIVISION <br /> 5155 Silverton RD NE <br /> .11 <br /> - Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> l <br /> PROPERTY OWNER: ( j\ ç\( ft C l bey n()L � <br /> gl <br /> SITE ADDRESS: 5M.,(0 Shaw NwN SE Aurnsv 1 I � OR 913D5 <br /> DATE: 3 d - 19 FILE NUMBER: 7407 - <br /> y <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: ALATia., 4111: r.) V u <br /> (Prope - or the Owner Authorized Agent) <br /> Name (please print): Cj` <br /> Company Name: +^ t } c <br /> Mailing Address: 58 214, &a.w <br /> 1\um v i`I Le,1 D R G13 25 <br /> Phone Number: 5O3 \ --L\?")(2)LA <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />