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I1 <br /> a'�k MARION COUNTY PUBLIC WORKS <br /> do1j���N BUILDING INSPECTION DIVISION <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: <br /> SITE ADDRESS: &77.iret, <br /> DATE: p <br /> FIL, ER: 2� — (7°14- l \AGE • <br /> • <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,and <br /> • the proposed development meets all minimum setback requirements from the existing septic system, and <br /> the future septic system replacement area. In addition if there isn't a septic system serving the property, <br /> • this document is to-certify that a full investigation has been made to determine that the parcel is not being <br /> 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.- he system a`-Sa to be functioning in a satisfactory manner at this time.. <br /> SIGNAT <br /> • p wner e Owner's Authorized Agent) <br /> Name (please-print): • <br /> Company Name: • • <br /> Mailing Address: <br /> • <br /> Phone Number: <br /> • <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 • <br /> Page6of6 <br />