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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> •-2 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: ( . aid f f(e �/ <br /> SITE ADDRESS: /2 4,M-y 7// , dX 9735Z <br /> DATE: "1/ 2y <br /> FILE NUMBER: 21i— 0026 D PI&F <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 or th wner's Authorized Agent) <br /> Name (please print): 1 L <br /> Company Name: <br /> Mailing Address: /Z 9 2i7A?wy Ih// 973�>_ <br /> Phone Number: -L nrs <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />