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MARION COUNTY PUBLIC WORKS <br /> �ll 11111 BUILDING INSPECTION DIVISION <br /> uir <br /> 5155 Silverton RD NE <br /> REepilvEn <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948M FEB <br /> http://www.co.marion.or.us 0 �012 la_ <br /> '� SIN ry CQUN-- <br /> • SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: 'N'e-?\1- csex- • <br /> • <br /> Sl'1'h ADDRESS: ( I Z 3 ( i?i by-\e_g_e- C <br /> DATE: coZ - ZoZZ <br /> FILE NUMBER: �a— • l 23 ) <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,thorou•hly inspected the septic system and found <br /> no evidence of any failure. The syste. appears to be functioning in a satisfactory manner at this time. <br /> SIGNATURE: , <br /> /(Prr,•erty Owner or the Owner's Authorized Agent) <br /> Name(please print): <br /> Company Name: <br /> Mailing Address: <br /> Phone Number: <br /> G:\FORMS\SEPTICIS-38 RR CerlificationFinaLdoc S-38 Rev: 9/10,1/11 <br />