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r <br /> MARION COUNTY PUBLIC WORKS <br /> '��I I. <br /> `t1j�11," BUILDING INSPECTION DIVISION , �(,� ('�� <br /> iun, <br /> �l`���� 5155 Silverton Rd NE /717 <br /> 4..; .' : 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, ii 41/1.0 no/ l/ fô y-r-/ ,have authorized <br /> (Property Owner/Print Name) <br /> ,2oG6 (A' <br /> Co n 5TrR 4 'n) 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 /> i <br /> PROPERTY IDENTIFICATION: <br /> —3 6 0 E C Ira-l'Ave. Gars 04' 773`/6 <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 /> / <br /> ✓ Printed Name: gi147 -7,0 vL� 6 L /t G `/ G-,-� <br /> / Signature: ,-,,d -4fze Date: /Z r/y to to / <br /> Address: 4 si? e 45 a l}p c'e Phone: 6-0 3- 10— 6W /11 d <br /> City, State, Zip _ Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 40y <br /> Company Name: /Q ,nsri'aci � <br /> Signature: Date: 12e/y�Z 0 2 D <br /> Address: , 9 6,/0 L e h Q4 on, 01� Phone: ,�G//— '/0 9".'r`�8Z <br /> City, State, Zip t eh osl a173 c� Fax: <br /> E-mail Address /f)G- nq f rep 6 u;llerj )"awe. 041 <br /> DEQ License# /fx 7-3-57 389.3o CCB# 2 0(r8 J <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> 1 .doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />