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�'" MARION COUNTY PUBLIC WORKS <br /> 4,1I 1114". BUILDING INSPECTION DIVISION <br /> 5 CI 5155 Silverton RD NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://wvvw.co.marion.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: STE*1�, Q-.(30 <br /> SITE ADDRESS: 6.SZ ( -tt to C i .e- - fLd •en-v-1 <br /> DATE: <br /> FILE NUMBER: a'�� � � 1 8) <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 /> • <br /> Name(please print): STD fe../A 1t�i <br /> Company Name: <br /> Mailing Address: (0 a(0 / .i-lut Cr'c t✓ i-c S <br /> Phone Number: c)-0(;) -'� G� <br /> GAFORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />