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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 /1www.co.mar;<on,or:us <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: /41, r 4^4. 1;i0ge 6e, <br /> SITE ADD SS: r y f2.7/ . � s <br /> DATE: Z4 fi <br /> FILE NUM®ER: / --as(Z,Z2l <br /> I certify that I have personally investigated the existing septic system on the above property and have <br /> identified th, exact location of all parts of the septic system,including the septic tank, distribution box <br /> or drop boxes, drainf eld.lines and future septic systemreplacement area. The attached site plan is an <br /> accurate rep -sentation of:thelocationof the septic system:and proposed structure(s) on the property, <br /> and; the pro e used development meets all minimumsetback requirements from the existing septic <br /> system, and t e 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 fall investigation has been made to determine that the <br /> parcel is not d eing served by a septic system. <br /> I further cert.' that I have,to the best,of my abilities,thoroughly inspected the septic system and found <br /> no evidence n f any failure. The system appears to be functioning in a satisfactory manner at this time. <br /> SIGNAT .3.0" <br /> (Property Owner or the Owner's Authorized Agent) <br /> Name(pleas- pprint): 1) / �;24 ( e tei <br /> � �� <br /> Company N. e: <br /> Mailing Ad. ess: a ., I A 4 <br /> Phone N>rrtb r r: ' V j 'fc 2W <br /> G,\FORMSISEPTIo S-38 RR CertificationFinal.doc. S-38 Rev: 9/10,1/1:1, <br />