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5CER7Efi\ <br /> JUN 10 2021 <br /> 4k,ii� MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION MARION COUNTY <br /> 5155 Silverton RD NE BUILDING INSPECTION <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: \AfeAto Le <br /> SITE ADDRESS: Y LO v-ear ccaS v y t E N.A.wtsv R c.-1,3 2S <br /> DATE: 1Q1ID* <br /> FILE NUMBER:S6 S--- -00004 4- MC <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: <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name(please print): ,4',#-(1.1 ( 4,b ie <br /> Company Name: n <br /> Mailing Address: ?.U 13o X Z.2-0 5u 1 I/41771-y OR- '7 3 6'c <br /> Phone Number: 503 01- 61 t' a q <br /> G:\FORMSISEPTICVS-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />