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MARION COUNTY PUBLIC WORKS <br /> di! �' BUILDING INSPECTION DIVISION <br /> .70 <br /> 5155 5155 Silverton RD NE RECEIVED <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MAY 16 2019 <br /> http://www.co.marion.or.us BION Y <br /> BUMILDING INSPECOUNCTION <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: C._Cz,,5 f, /// <br /> I <br /> SITE ADDRESS: I 0 9 02- St. LL 'A i 2c iVE <br /> DATE: ,S m 16 I <br /> FILE NUMBER: \ ,to 51 ]-At € <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: 1 ‘....6,4 <br /> Pro <br /> (Property the Owner's Authorized Agent) <br /> ( PrtY g ) <br /> Name (please print): (? 1 5 P 54ie. � l <br /> Company Name: <br /> Mailing Address: <br /> Phone Number: 5Q 5.45' I1 `7 S <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br /> 5 <br />