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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 /> ` http://www.co.marion.or.us <br /> SEPTIC SYSTEM CERI]Y ICATION for RECORD REVIEW <br /> PROPERTY OWNER: (ZFrt7 (T y7 Cd7 <br /> SITE ADDRESS: /D‘ C.e2)eQ -ii A 1>2 l� ���e� �s ,o4 /7'2-- <br /> DATE: //b// <br /> FILE NUMBER: __/ o__-- �-i <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 structures) 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: �i <br /> - N. <br /> 1 <br /> =. <br /> Property • • .er or the !• .er's Authorized Agent) <br /> Name (please print): alp _ f L AL <br /> Company Name: <br /> Mailing Address: /0.4 n7 (0%,.a_fha.)/ <br /> 0,0_417,k, c (7,z 570z6 <br /> Phone Number: So cf 9/ /Z37 <br /> • <br /> G:IFORMS\SEPTICIS-38 RR CertificationFinaLdoc S-38 Rev: 9/10,1/11 <br />