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IVIAKION cuuni J.J. Jr v.u.ut.. ►► <br /> ,111 ,ktintu� BUILDING INSPECTION DIVISION <br /> , `�� `� 5155 Silverton Rd NE <br /> .., = - �;,. Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> httpalwww.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I,A'yA- a.. � . have authorized <br /> (Property Owner I Print Name) <br /> I b `- -c 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 /> • <br /> PROPERTY IDENTIFICATION: . <br /> /.J chi 5 p/e.--rg,e—e' R (4 . c5,6= 71 7Le-fr.e9A f713.7- 7 <br /> Property Situs or Street Address . <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block . <br /> PROPERTY OWNER: <br /> zikAl <br /> Print <br /> ed Name• 4. ;�� Ltb�' ��� "' Z <br /> Signature: • Date: <br /> Address: 5 e,z.3 . /rSct/-‘`& { !./,// ,4 Phone:J'3 ?41 53A-`t <br /> City, State,Zip 7-6-c_1'vL-e-r C:5/ `f 7.-/1 7- Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name:1)rf.a..l ��l�`���f�Y\ C X. <br /> Company Name: <br /> Signature: <br /> Date: 4- 425-- a.3 <br /> Address:c5 0,.,3 2W „./yrd.14 bell /.'d.--- Phone: p-d; ?6 f i?�1' <br /> City, State,Zip ,7�/. d g > ,�J ' . .`-- Fax: <br /> E-mail Address <br /> DEQ License# • CCB# <br /> G_\FORMS\SEPTICIS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 • <br />