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• <br /> t'�� MARION COUNTY PUBLIC WORKS <br /> ,,I1 ..1114". BUILDING INSPECTION DIVISION <br /> ��%���� 5155 Silverton RD NE <br /> Salem OR 97305 <br /> mig (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us <br /> • <br /> SEPTIC SYSTEM CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: V(,il✓1L Lf Lb C ESOil <br /> SITE ADDRESS: 22-S5 I2{/k(Vi S D4 N E( Sa Lvv) <br /> DATE: PIS— 19 <br /> FILE NUMBER: �J%— )9- bO 35 1.18--A Gr--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, 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: A l <br /> _.------ <br /> .6,e er or the Owner's Authorized Agent) <br /> Name (please print): ?Oj/' k'.( (,)(ACS. suV1 <br /> Company Name: <br /> Mailing Address: 22- 5 fkiris 5+- N t, <br /> Sa,l r, , OP- 9-7 303 <br /> Phone Number: ( O3) 432. -6 jjO Li <br /> G:\FORMS\SEPTIC\S-38 RR CertificationFinal.doc S-38 Rev: 9/10,1/11 <br />