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COMMUNITY DEVELOPMENT <br />DEPARTMENT <br /> <br />Marion County Building Inspection <br />3150 Lane. aster Dr NE - Suite C <br />Salem, Oregon 97305-1398 <br /> <br />PIt# 588-5147 <br />FAX//588-7948 <br /> <br />SEPTIC SYSTEM CERTIFICATION <br /> <br />PROPERTY OWNER: <br /> <br />SITE ADDRESS: <br /> <br />ACTIVITY NUMBER: <br /> <br />I certify that I have personally investigated the existing.septic system on the above property and <br />have identified the exact location of all parts of the septic system, including the septic tank, <br />distribution box or drop boxes, drainfield lines and future septic system replacement area. The <br />attached site plan is an accurate representation of the location of the septic system and proposed <br />structure(s) on the property, and the proposed development meets all minimum setback require- <br />ments from the 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 and <br />found no evidence of anY failure. The system appears to be functioning in a satisfactory manner <br />at this time. <br /> <br />SIGNATURE: <br /> <br />Name (please print): <br /> <br />(licensed septic installer, septic consultant or owner) <br /> <br />Company Name: <br />Mailing Address: <br /> <br />Date: <br /> <br />MCI5-S38 <br />REV 6/98 <br /> <br /> <br />