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3150 Lancaster Dr NE - Suite C <br />Salem, Oregon 97305-1398 <br /> <br />PH//588-5147 <br />FAX//588-7948 <br /> <br />SEPTIC SYSTEM CERTIFICATION <br /> <br />PROPERTY OWNER: <br /> <br />SITE ADDRESS: <br /> <br />SITE NUMBER: <br /> <br />I, hereby, certify that the attached site plan is an accurate representation of the conditions on <br />my property, and that the proposed structure meets all minimum setback requirements from the <br />existing septic system, and the future septic system replacement area. <br /> <br />I further certify that I have, to the best of my abilities, thoroughly inspected the septic system <br />and found no evidence of any failure. The system appears to be functioning in a satisfactory <br />manner at this time. <br /> <br />(prop~cty owne'r ~r authorized agent) <br /> <br />DATE: <br /> <br />Name (please print): ~' .-~ ~/)~Ne <br /> <br />Mailing Address: <br /> <br />MC15-S35 <br />REV4/97 <br /> <br /> <br />