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tk MARION COUNTY PUBLIC WORKS D U <br /> �� �����"� BUILDING INSPECTION DIVISION C E �'I <br /> � w 5155 Silverton RD NE t n <br /> Salem OR 97305 JUL 1 0 2023 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us MHkION COUNTY <br /> 3UILDING INSPECTION <br /> " D Ikksei-D\r ( <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: /arovt d tr <br /> ) <br /> SITE ADDRESS: f J 73 7 1 L U we —R cot SE . SGc.{j'�`w� <br /> ) <br /> DATE: — IDfiCZJ <br /> FILE NUMBER: 3 -0 OS g I O j -00 S 8 ( (- <br /> I certifythat 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 /> r <br /> pertly Owner or the er's Authorized Agent) <br /> - Name(please print): /- �'T T`fe <br /> Company Name: KCCL.S <br /> Mailing Address: T . 0 . F O K ( /- rc,vt'ft t C17 3 Z S <br /> Phone Number: -3 - l00 Rf i <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinaLdoc S-38 Rev: 9/10,1/11 <br />