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"k MARION COUNTY PUBLIC WORKS <br /> dii ,11j11"14tr BUILDING INSPECTION DIVISION <br /> .4mr�� � �� 5155 Silverton RD NE <br /> Salem OR 97305 <br /> 1.11 (503)588-5147 Fax(503) 588-7948 <br /> http://vvww.co.marion.o r.us .. \q5 -)5 ( <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: &L& (D'GC.`C-�lyv\ct l✓\- <br /> SITh ADDRESS: 760 l ri k AUK / vc <br /> DATE: ' 7- ' ' " 202 Z <br /> J 1LE 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,thorou•hly 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: l —(Property Owner or the Owner's Authorized Agent) <br /> Name(please print): ?}s av _ 0ec- c-e k ,0,v)". <br /> Company Name: <br /> Mailing Address: 7S 6 L 17 f' A i N E <br /> 1..ke,,,,- c,<2 q7 31 1 <br /> Phone Number: 5 v S 4 411 7 3 D, <br /> GAFORMS\SEPTICIS-38 RR Ce±fcationFinal.doc S-38 Rev: 9/10,1/11 . <br />