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�'" MARION COUNTY PUBLIC WORKS <br /> do 1'1j�Nul BUILDING INSPECTION DIVISION <br /> 5155 Silverton RD NESalem OR 97305 <br /> MI• (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us <br /> /116 Zk.11 rn- <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER 2111A0 wG)(le-r <br /> SIIEA.DDRESS: 90 S Sonnyviccw 2c.1X)E Sa(sri4 97-.30c <br /> DAZE: 3 — l2- 20)? <br /> FILE NUMBER: / 9 s&0715 d/ — "fe'E • <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, drain-Reid 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 /> • <br /> I <br /> SIGNATURE: <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name (please print): l<rChord/ 64;46k— <br /> Company Name: e---21/1/7)/ 060v At kaJo rS iovG� /(4/411-2c <br /> Mailing Address: 9oFS---- SU44yvJ6W V XJE <br /> S (6.04, 002 9 730.c <br /> Phone Number: co 3 cat - ?20 <br /> • <br /> • <br /> G:IFORMS\SEPTIC1S-38 RR CertificationFinaLdoc S-38 Rev: 9/10,1/11 <br />