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11 <br /> MARION COUNTY PUBLIC WORKS 7 (X/-(i/5 <br /> 41�� ,1������'' BUILDING INSPECTION DIVISION RECIIlEr'- <br /> 555 Court St. NE Room 2260 /PO Box 14500 <br /> Salem OR 97309-5036 <br /> (503) 588-5147 Fax (503) 588-7948 MAR Z d � J7 <br /> http://publicworks.co.marion.or.us/building/ • MAR <br /> COUNT' <br /> 8UILDING INSPECTIoN <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: )Q✓e 4- L.in d A 41wt en(4;0.5 c r <br /> SITE ADDRESS: 95`f e /01- D r. S. e w.. <br /> DATE: .3-,? - o 7 <br /> FILE NUMBER: 0 ! Q/S 00/ <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. <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: <br /> (Property Owner or the Owner's horized Agent) <br /> Name (please print): <br /> Company Name: <br /> Mailing Address: <br /> Phone Number: <br /> S-38 <br /> Rev:8/00;3/03;3/05 <br />