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4''� MARION COUNTY PUBLIC WORKS <br /> ���I 1j1j�1iii" BUILDING INSPECTION DIVISION <br /> 5155 Silverton RD NE [ <br /> HIS Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948ORY <br /> http://www.co.m arion.o r.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: h/IA l vc 6c vaj <br /> SITE ADDRESS: 6ros y Pt tuo 4cgorr, GAt. <br /> DATE: 8 s- 'LO 2 V <br /> .,FILE NUMBER: 0-S- - DO I,G- A =. <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: \f <br /> (P erty Owner or the Owner's Authorized Agent) <br /> Name (please print): <br /> Company Name: <br /> Mailing Address: <br /> Phone Number: <br /> G:\FORMS\SEPTIC1S-38 RR Certifi • onFinal.doc S-38 Rev: 9/10,1/11 <br />