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MARION COUNTY PUBLIC WORKS • <br /> .111 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 CERTIFICATION for RECORD REVIEW <br /> PROPERTY OWNER: ,162,A-)4eArrdtfvtls <br /> SITE ADDRESS: 4 L VNci'or4o;A-k r2a. ►AXE '11 vr.+-ft vt U 2 <br /> DATE: "" e--d 23) 20 161 <br /> FILE NUMBER: /9a99 ,4L <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: -6gtiA_C <br /> operty r or the O er s Authorized Agent) <br /> Name(please print): T& e Q.,'�q <br /> 0 <br /> Company Name: <br /> Mailing Address: 414M V.1-da 1>o i r * Y2d M <br /> I verly kt., O 2 17 3 g( <br /> Phone Number: S0 3 •S'Oq •26 3 e3 <br /> GAFORMS\SEPTTCIS-38 RR CertificationFinaLdoc S-38 Rev: 9110,1/11 <br />