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al-bbLka1 <br /> MARION COUNTY PUBLIC WORKS VIE; <br /> BUILDING INSPECTION DIVISION D CLI �`� I <br /> ____,___.„. ...,_=,„ 5155 Silverton Rd NE <br /> Salem OR 97305 2 3 L L m <br /> im <br /> (503) 588-5147 Fax(503) 588-7948 MARION COUNTY <br /> http://www.co.marion.or us/PWBuildingInspectiTUIr..DING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I. J cob 6141111% ,have authorized <br /> (Property Owner/.Print Name) <br /> LW Stinky Environmental Vie,Inc. to act as my agent in performing the <br /> (Authorized Representative 1 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 /> a3g5,5 5c0±1- Ln- AI ,& rorc )R, 97O0a <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> i'ROPERTT OWNER: <br /> Printed Name: Jae-46 £'m!/t_ <br /> Signature:x Date: 171-5"au! <br /> Address: '55-5 /At•4.6€.. Phone3)33y7` q <br /> City,State, Zap AGe ebir4.) 012 q'7 o OA, Fax: <br /> E-mail Address J o6s1ni it.3 ei701,511, C0/41 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: On S U0-51/fr.-- <br /> Company Name: til' Stinky Environmental Service, Inc. <br /> Signature: Date: cl-'I_),1 <br /> Address: /?Co / /(+i -,Q Phone: o ' )\ VS <br /> City,State, Ziprti I' l At t k _ 11Q' Fax: <br /> E-mail Address (��XX 5 (-xi") ‘1).3161":1-? <br /> S\A _ J -C�`3- <br /> DEQ License# Jg 1 CCB# I g c kt `11"j.. <br /> G:1FORMS SEPT1COS-07 Auth to Apply.doc <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />