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4° MARION COUNTY PUBLIC WORKS <br /> 1j������'"� BUILDING INSPECTION DIVISION <br /> 5155 Silverton RD NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://wwvv.co.marion.or.us • <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVTEW <br /> PROPERTY OWNER: ,09 16,E ,,,��\ L-Q <br /> SITE ADDRESS: ( C k <br /> DATE: \q/--1 <br /> FILE NUMBER: 55s - of -OD1 AC2e <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: �r <br /> (Property Owner or •- Owner Authorized Agent) <br /> Name (please print): L <br /> Company Name: \ kDe \&.w`, 1 uN <br /> Mailing Address: 13g \,4 Q D`E) L QA t t L <br /> -��r,16" <br /> Phone Number: 5 3- (p 6 <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />