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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 /> PROPERTY OWNER: `-raoSA baV 16b S C.-M1S >PR._ <br /> SITE ADDRESS: 233 LI �z�,� V C & _ oAD 141 Scc,rrs 111-lS OE C(7375 <br /> DATE: .A w+si 7�, 2_0/A <br /> FILE NUMBER: d l'C05 I '/46c <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, drain-field 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 the Owner's Authorized Agent) <br /> Name (please print): D , - A. S c c <br /> Company Name: <br /> Mailing Address: P. 0. sr* No 9 <br /> GRA M , baEGDQ 302-- <br /> Phone Number: (SD3)51r.'1- CAMP <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />