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® t <br /> �����, MARION COUNTY PUBLIC WORKS <br /> 'glI �'ii"'' BUILDING INSPECTION DIVISION <br /> �� Z- 5155 Silverton:Rd NE <br /> IIIiij <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I. ' 644 g B Oki- Coov .5 ,have authorize-1 <br /> (Property Owner/Print Name) <br /> • _rica a✓i &ei 1'a wl I ri rrra lick r t.i I t14 Exca. ,o hto act as my agent in performing the <br /> Authori d Representative/Print Nam <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 /> 3 S / I Meiviovi t - S� 1 ,-- O2 q 73 I r- 7 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: <br /> Signature: Date://4/4 / <br /> Address: 3 l CC 4plory Le -e- e Phone: 5o5- g3o -37q/ <br /> City, State,Zip $e4* C, q 7 3t 7 Fax: <br /> E-mail Address �.Q via d .7gs, 44,4 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: J c r..,ri &vt''e w1,✓\ <br /> Company Name: ,ri :rY+t4i c.icil/1 Frc.etiv41."0 \ <br /> Signature: Date: O5 -O(( - a. / <br /> Address: p 0 l )x 670 Phone: (50 ) p8-/ - 6A 16 <br /> City, State,Zip L„/c,or (:)/L 9 735 a Fax: <br /> E-mail Address 6 .,,,,,d}yec; exc @�J C1 on.,I, (0,,, <br /> DEQ License# 3, / 9 1 CCB # 02 117 3 I <br /> GAFORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br /> I <br />