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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton RD NE <br /> • Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> ht-tp://www.co.marion.or.us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: '(6t,)-7 47/7 /7 <br /> S1'lr ADDRESS: /Q‘o2__ )2 J� � 6iotena.(5- /7. 2d <br /> DATE: 7//b// <br /> FILE NUMBER: F\— (2(g, .7 • <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: 9i�- ' <br /> ` Property •wner or the,e 'er's Authorized Agent) <br /> Name (please print): ap A. <br /> Company Name: <br /> Mailing Address: /Ql Oz 1.6)%e / A,9 <br /> 0,0_,Lve.,, 5 OR-- <br /> Phone Number: 50 /Z37 <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />