Laserfiche WebLink
*k MARION COUNTY PUBLIC WORKS <br /> 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 /> . <br /> PROPERTY OWNER: LI /4 .°5 <br /> SITE ADDRESS: pc.P Z�y I ? sit <br /> DATE: 167 <br /> FILE NUMBER: 2-4— 41S96 A 6 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: ' <br /> (Property Owner the Owner's Authorized Agent) <br /> Name (please print): Lam. Li ,,� <br /> Company Name: A% <br /> Mailing Address: dr2,0$3 2g /.4 A1,i/ <br /> vSi /l <br /> � '9737 <br /> Phone Number: 7 f fl'A 2-T a ' 17 <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />