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1'�� MARION COUNTY PUBLIC WORKS <br /> ,iii 1j���iii"' BUILDING INSPECTION DIVISION <br /> %`��N 5155 Silverton RD NE <br /> Salem OR 97305 <br /> no (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us <br /> . SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: /14/C/FA GL-- W t Y"','7 <br /> Sa.b ADDRESS: 394 ( v17-71 E 51")2,IA/C76 2/- S 14671 <br /> DATE: • <br /> FILE NUMBER: <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: h -/ <br /> d4 <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name(please print): MI cirA-L Gf 1 Tt'7 <br /> Company Name: <br /> Mailing Address: 394 1 V/174 E. 577,2/n14 s -� S <br /> �AC&,u OR, 5'.4- 3aC <br /> Phone Number: Jr-p j .`_7_ 96 " 2_3 ©/ <br /> G:\FORMS\SEPTICIS-38 RR CertifcationFinaLdoc S-38 Rev: 9/10,1/11 . <br /> 1 <br />