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• MARION COUNTY PUBLIC WORKS <br /> mfRp4 "'" BUILDING INSPECTION DIVISION <br /> 5155 Silverton RD NE <br /> Salem OR 97305 <br /> MM. (503) 588-5147 Fax(503) 588-7948 <br /> http:/1wwvw.co.ma.rion.or.ns <br /> • SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: l( 2(,,,,r1 col ( i c . <br /> SITE ADDRESS: 2_0 12._ Cn ) '-n (J, j L <br /> DATE: <br /> FILE NUMBER: 19 -(0LI f <br /> • <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, inclining the septic flank, distribution box <br /> or drop boxes, drainfield lines and future septic system replacement area. The atfarhed site plan is an <br /> accurate representation of the location of the septic system and proposed structore(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 annition 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,thoronedy 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 /> (Property Owner or the Owner's Authorized Agent) <br /> Name (please print): "-Pi,,,,>1• <br /> Company Name: JlL ,� ,� S A <br /> mailing Address: 2..em 12 (q z <br /> , 1,.5 -,,,./. 973n5, <br /> Phone Number: -? ©_Zo a- <br /> Q:WORMS\SEPTICIS-38 RR CertificationFinaLdoc S-38 Rev: 9/10,1/11 <br />