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3150 Lancaster Dr NE - Suite C <br />Salem, Oregon 97305-1398 <br /> <br /> 588-5147 <br />FAXg 588-7948 <br /> <br />PROPERTY OWNER: <br /> <br />SITE ADDRESS: <br /> <br />SITE NUMBER: <br /> <br />SEPTIC SYSTEM CERTIFICATION <br /> <br />I, hereby, certify that the attached site plan is an accurate representat!on 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 ave~nspected the septic system <br />an~add~rUna~t~; ~.vidence of an ' ' ' ina ' c <br /> <br />SIGNATURE: ~ <br /> (property owner or authorized agent) <br /> <br />Name (please print): <br /> <br />Mailing Address: <br /> <br />MC15-S38 <br />REV 4/97 <br /> <br /> <br />