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�'" MARION COUNTY PUBLIC WORKS <br /> ���� �,�1�����"� 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: ALCUA'`)Ay 1vx4 <br /> SITE ADDRESS: I 11114 VvAU)O ,�l,u Th . SAuem. CZ. 7317 <br /> DATE: Li- 9•14 <br /> FILE NUMBER: ` "CX A66 <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: v• � <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name (please print): if:R\--)P9.3 <br /> Company Name: tee_ <br /> Mailing Address: EI)C0 AV3 Ca-WELL El L AOC. <br /> CJpuis ccZ- 173o <br /> Phone Number: � "eS 13 <br /> TvrwA-Ct., — J;1ac�T.V 1O1oro 4, G^ . Co-nn <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />