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• asitigkik. MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> -=- <br /> 5155 Silverton RD NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax:(503)588-7948 <br /> http://www.o.tnarion.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: IPA /(Aki-serles. .1fric <br /> SITE ADDRESS: -„a3.(,(1. ilupe,,jes- Rd gii..4--op„_ oe 7,7 boz_ <br /> DATE: <br /> PILE NUMI3ER: S.55-1.2-007343•-•• <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, drainfieki 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 mariner at this time. <br /> • SIGNATURE: <br /> (Property OvVher or the Owner's Authorized Agent) <br /> Name(pleaSe print); hi?tn /Vay <br /> .51)A <br /> Company Name: Ait,,r ute-_5 6. <br /> • Mailing Address: d3&vo <br /> Aurrros OtZ 0-0 <br /> phone Number: (SO) r- o7a6, <br /> GAFORMS\SEPTILAS-38 RR CcrtifleationFinal.doc S38 Rev; 9/10,1/11 <br />