Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> INI*. <br /> BUILDING INSPECTION DIVISION <br /> 4e <br /> 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: irn pay Lo Q1 d n <br /> SITE ADDRESS: I 3 5 j s Arkv-b-ed e r- R (114-e5 OR cif 3 <br /> DATE: Gur-c. h 1 4 0-0 a L <br /> FILE NUMBER: � d 6 2'Z ZU -/ I- <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: t �O.-(,�, --E °cLu f � <br /> rope Owher or the Owner's Authorized Agent) <br /> Name(please print): ma r-U I..-(�u ejo ld L Y• l_ <br /> Company Name: E \- —n-e d P r � l to �-i v y �e (� V0. rS n <br /> Mailing Address: p , l7 O X 5 I^ J <br /> o-L�� O� 9(18 � f <br /> Phone Number: (SO 3-) 11-q g - 3 <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />