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• <br /> RECEIVEn <br /> DEC 24 2020 <br /> � <br /> ��� MARION COUNTY PUBLIC WORKS C 6 <br /> ',I ���',''m. BUILDING INSPECTION DIVISION MARION COUNTY <br /> j � 5155 Silverton Rd NE <br /> BU LDING INSPECTION <br /> 'a" `' `-` Salem OR 97305 2034Ge(3� <br /> MI (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE• <br /> I, P,5 -3-' ;CI lie O ,have authorized <br /> ���� (Property Owner/Print Name) <br /> ��'.e �pk, C'a to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits, and other onsite wastewater treatment program <br /> services provided by the Department of Environmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: . <br /> 1009,5 \- v Lin . L1 btr\s 1 DK 91X6 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as' <br /> Legal Description Tax Lot#(s) 0015E.oaDe 01 i On <br /> PROPERTY OWNER: <br /> Printed Name: ,/at re ,Z <br /> ✓� t 7�_s Date: j�P /2 a/`Z�'Zo <br /> Signature: � L�t� , <br /> Address: PO 1e-IX: 5'1 4,c, Phone: ,03 _We if - x"4'7 0 <br /> City, State, Zip .)4-LE)L-1 , L)P q-7304 Fax: <br /> E-mail Address ,...66 "Etc r ft14 a L ` L,,s4 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: -F„,1 ( F. k c ) L4,v <br /> Company Name: fes, 11 cg$ 14 a,v c-5 L L_ C , <br /> Signature: Date: P _ ( ( i 7n 2 <br /> Address: 2RO / 5,0 c: k ic;k, k ok (V.L. , Phone: 5 O 3 - T7 I - 30 o Q <br /> City, State, Zip ‹ (e_pri. U .i 91 3 0-S Fax: . <br /> E-mail Address {-6 kc,c.J,, 5 6 a r , C6 t--L <br /> DEQ License# RI 751 72-,V62 CCB# 71 C 311 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />