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C <br /> ' MARION COUNTY PUBLIC WORKS <br /> .01104k',, <br /> '''i BUILDING INSPECTION DIVISION <br /> . <br /> . %`",N.4.• 5155 Silverton Rd NE • <br /> . Salem OR 97305 <br /> (503)588-5147 •Fax(503)588-7948 <br /> 11 <br /> http://www.co.marion.or•.us/PWBuildinglnspection ••1. <br /> . NOTICE AITIIIORIZING REPRESENTATIVE <br /> I, Judith A James ,have authorized <br /> . (Property Owner/Print Name) <br /> ' Ace Septic Service 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 /> B737.Arbnrrialp Or SF Salem OR A7317 . <br /> • Property.Sites or Street Address <br /> • And described in the records of MARION County as: <br /> Legal Description. �`6Z-Vnl 0"1�t-i O O 5.0b0 Tax Lot#(s) V DOD <br /> . PROPERTY OWNER: . <br /> Printed Name: Judith A James • <br /> Signature: 4 5 Date: 5/3/2022 <br /> • Address: 6237 Arb dale Dr. SE Phone: 971-239-5518 <br /> City,State,Zip Salem OR 97317 Fax: <br /> • <br /> E-mail Address rainspring.mdg@GMAIIL.COM . <br /> AUTHORIZED REPRESENTATIVE: • <br /> Printed Name: kA 10- .0 Ct I( C(3 <br /> Company Name: Q\ C, • <br /> Signature: —1 Date: t 2 <br /> Address: 1 O-Q t eO ?O(\and gC.y Phone: �3- 3— ( S <br /> . City,State,Zip O2-. 9120 • Fax: . <br /> E-mail Address V•2. 1 ('ct @- a-C e_.— `�,c. L. d.I � <br /> DEQ License# • ?2JC CCB# el1 `I <br /> cts <br /> c:1FORMSSBPT!C\S-07 Auth to Appiy.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />