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tk MARION COUNTY PUBLIC WORKS <br /> ,iii "� BUILDING INSPECTION DIVISION <br /> l�%l-. �� 5155 Silverton RD NE <br /> img- Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.onus <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: S-VE*,3 ( k ef)(La <br /> SITE ADDRESS: esg 6 (2r t2 C r(„e-st- fLd 5b .i r Q2 1.1. r j <br /> DATE: I t L),v <br /> FILE NUMBER: o2„,:7.-FjpC\cc \c:\ <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 /> ,,-) - <br /> SIGNATURE: CIK---)--A-2,r'.. --.1.'4___ <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name (please print): S T��l4.-n izi i(-0 <br /> Company Name: <br /> Mailing Address: (oia l0 1x.. tE- C r.0 e K Pct V, <br /> £c t e c - cn>l� <br /> Phone Number: v)-061 ` ' 1-"lc°I,G <br /> G:\FORMSISEPTICIS-38 RR CertificationFinaLdoc S-38 Rev. 9/10,1/11 <br />