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, l,-.. n�1"b11%. <br /> � MARION COUNTY PUBLIC WORKS <br /> b` BL LDING 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:Ad; .ru�� jk .t L. /�,r ,,. J <br /> Sl lb ADDRESS: „�3 S c1 /3CL+�. ca.wa dYCu� ��"�_ <br /> .0 •�') _' ( ()q 735s <br /> DALE: ,,2—f„, p18 <br /> - <br /> FILE NUMBER:Cd4t -i ' D. <br /> 6:cc- g-coo _nig y' <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: sYs) r>~ .Pcuore,diejz, 2A)). <br /> (Property Owner'o the Owner's Authorized Agent) <br /> Name(please print): 3n; F p,,,i „ <br /> Company Name: kVA - - <br /> Mailing Address: PO/ f� '19 LinnS ()Rq'(.358 <br /> Phone Number: ZO - NSA - <br /> • <br /> G:/FORMS`SEPTICS-38 RRCatificaaoaFinal.doc 5-38 Rev 9/10,1/11 <br />