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0'" MARION COUNTY PUBLIC WORKS <br /> ���I t11j�����'' BUILDING INSPECTION DIVISION <br /> • <br /> 5155 Silverton RD NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: ( e i r IM(Clio Lk e_e 11o� <br /> SITE ADDRESS: tee[),' (,co vie E �—}�t bbelwC( ie. 7 703 2 <br /> DATE: g—('f--2 3 <br /> FILE NUMBER: 9 .2-7 C 1Pr G E <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: drAi <br /> . <br /> (Pro s erty Owner or the Owner's Authorized Agent) <br /> Name (please print): Yi - �, e�(( <br /> Company Name: <br /> Mailing Address: 19 l ( t veil; (,..e,yq . E, <br /> Phone Number: .'03 73/ 22 -4 2— <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doe S-38 Rev: 9/10,1/11 <br />