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�'�� MARION COUNTY PUBLIC WORKS <br /> "'' BUILDING INSPECTION DIVISION <br /> ��i% ;mi. . ,E.,,,, . --- 5155 Silverton RD NE <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 /> PROPERTY OWNER: S–Ce-A / eS, L-Lc_ .. /'4.- rs S--F�me <br /> SITE ADDRESS: W(0 -1fI 01 OC <br /> DATE: 5 / IF <br /> FILE ER: v AY() , <br /> q 0O3 ZZ _ i\ 6 , <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 /> 1 ',.\\ <br /> kA <br /> SIGNATURE: , /, r, - 71 1 / <br /> ' tri <br /> operty Owner or th- Owner' uthorized Agent) <br /> Name (please print): eA,P-A._ 5Y—Cc. 1/1-/e 7' <br /> �-r <br /> c <br /> Company Name: ,t /e r c e6 UL <br /> Mailing Address: P 0 B p f P l /A ' 0 S <br /> .5/VsY\/ 0 '773 <br /> Phone Number: 66 3 -S 05-`010/ 1 <br /> cO r13 ( - ,23y7 - ce (( <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />