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„�i �'��►►,,,�► ` MARION COUNTY PUBLIC WORKS <br /> ►�"”' BUILDING INSPECTION DIVISION <br /> i `��`�� 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: e4 5cit Lalc> <br /> SITE ADDRESS: 56 f 3 OLb nte/hah+.ct 542y/0i-t O ?73” <br /> DA 1'E: 7-2. - <br /> FILE NUMBER: 21, 00 5-7 56" I"I &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 theseptic system and found- -- --no evidence of any failure. The system appears to be functioning in a satisfactory manner at this time. <br /> SIGNATURE: ALd4 <br /> (Prope caner or the Owner's Authorized Agent) <br /> Name (please print): <br /> Company Name: <br /> Mailing Address: <br /> Phone Number: <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc 5-38 Rev: 9/10,1/11 <br />