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�`�� MARION COUNTY PUBLIC WORKS <br /> AlI 417 BUILDING INSPECTION DIVISION <br /> � �� �� 5155 Silverton Rd NE <br /> m— ii Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, J c,. fat ( rF 4 -Pyt,-- , have authorized <br /> (Property Owner/Print Name) <br /> • ' �-\--eve. C-U k .+ to act as my agent in performing the <br /> (Auth zed Representatve/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 /> 1 Z d ,ems a . --Q, 45 ,� c_ `( Z 2. <br /> PropertyySitus or Street Address <br /> And described in the records of MARION County as: S A. F-L' <br /> Legal Description G. i 6 j P _ '3 La ( , � c ., Tax Lot#(s) Q [ ,Z 226 Cs <br /> PROPERTY OWNER: 2_Sc_-. ) 2�ae <br /> Printed Name: ' 4, yk <br /> Signature: A, r Date: 7(7-Zi Z _ <br /> Address: . /S c- le, 1 jrt ed. S r Phone: C4'( -" 9 7'-/G 72., <br /> City, State,Zip j 6, ► ia, e„iz , 0 9`7-3 6-- Z Fax: <br /> E-mail Address [vi J3 S IAD,I'y J a'I o L'0 14-1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: U� \lam• L D <br /> Company Name: 4,',4 <br /> Signature: ,_ Date: `(! 2 i 2.. - <br /> Address:-1A2,.5 �4 1 41..r Phone:, a 17 2 ' tit . <br /> City, State,Zip 6 4 r-cz^-,-, l 0!2 Z a 4::3 < Fax: <br /> E-mail Address ,r^co. b ..-,-)?. C ez-.-- , c.c.=-.--, <br /> 1 DEQ License# / CCB# 4. <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />