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- - <br /> MARION COUNTY PUBLIC WORKS Q. <br /> BUILDING INSPECTION DIVISION E <br /> u (--/7' EL]V Eh <br /> 5155 Silverton Rd NE ii1) <br /> .., _ .. Salem OR 97305 APR 0 8 2022 <br /> 1111.1 (503) 588-5147 Fax(503) 588-7948 <br /> http:/lwww.co.marion.0 r.uS/PW/BuildingInswitik l'1.-li i''4 COUi\rry <br /> ....- diGs INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> aw Si-0 A Ce.:3 L. iiiic_68,11Lee. , have authOrized <br /> (Property Owner/Print Name) <br /> V‘c" "\" C'''''' ''`A`'''''` ic,1. 1 -T•flcc 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 IDENTEFICATTON: <br /> ,, <br /> q6Ia. v-e_ f-.t• onO 'e,r a <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description ocrsw-$C. Tax Lot it(s) ocAoa <br /> rPROPERTY OWNER: <br /> il Printed Name: Stet IA Ie_...%-i L. /14 c e.,1.4e.e' <br /> 1 Signature: 6) ..II° ilc1LA p.R.,_ Date: /fp ril s,th i 2.0 22•S' 42( <br /> Address: Z73/3 4ette._ Or Phone: 5 Lei-'NO--gei 0? <br /> City, State,Zip Litiai 4'.611 i C g. q 7,?c c Fax <br /> IP-mail Address 51-4 4 4' ilAL 5,..t,,e0 yet..two. co LAA <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 'tot c.-, 1-"Yter <br /> Company Name: 9....*4.Y.. W.\ ( icon,,v ciAtA4 tteN <br /> Signature: g-f-ei, 442,--- Date: 24-6-7.1_ <br /> Address: ';'/.12z3 (-AA-'r a.4- .- Phone: S LI 1-lo,II-ecisei <br /> City, State;Zip Lebe...."a, • ck-1-5s T Fax: • <br /> E-mail Address a i....., ) coc_NA.:,,, c.... <br /> DEQ License# 3.1 CMCIk • CCB 4 -2,.‘0,2_52- <br /> GAFORMSISEPTIOS,07 Auth to Apply.doc <br /> • MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />