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MIIIII <br /> 41 ,'" r,,; MARION`COUNTY PUBLIC WORKS <br /> .., <br /> 7s �.g' BUILDING INSPECTION DIVISION <br /> � `-- 5155 Silverton Rd. NE <br /> Salem OR 97305 <br /> .I " (503)588-5147 Fax(503)588-7948 <br /> k,,. ': a f; lilt /.-".- V..4 a, p: /www.eo.marion.or.us/PW/BuildingIns <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, L✓C&t:\r ty-v . Cl s,. '_t. , have authorized <br /> (Property Owl cr.I rint Name) <br /> i 1(11 cl tS to act as:my agent in performing the <br /> ( uthotizedRepresentative 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 chapter340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> /. . J ►q AM N. SE . ; I Cc 735 <br /> roperty Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot u(s) <br /> PROPERTY OWNER: <br /> Printed Name:.,- 'C. il Cck, e�r <br /> Sgnatur ' 1)r Date: 3/4-2/ 3 <br /> Address: G C 1-q..rlL i! ti (L .Se.__Phonie: 5ti Li" ,0 '' Sa.. <br /> City, State,Zip 4*`f1S. ` . P-,_. Gf'. 5_ Fax: <br /> E-mail Address L„c <br /> fCUTIJOIll ';J I) Itilr1'i„:'.tz l l' f70 l\ lb <br /> Printed Name: <br /> _ _t <br /> CQnlan Name: . _ s_. ' S .�cy <br /> SI,nature: ,�..-. Date, <br /> _ Lr�2� __. . ..___�_.._ __._. ,_.. _ aj;r�i_I j <br /> Address' `d SPhone'-___- 1, __.'� � 1 q.DGl. �9.�-1___ <br /> City, State,Zip V`'1,A(}K\ ,.1 Mti'1 q1 1 Fax: <br /> i -mail lcltl,t <br /> �n te,hmbes elcave• 1 cn - Cow <br /> . <br /> DEQ License li 5 J CCl3 ii � <br /> .gip�_w_ ,__.. �.._____�.__�.�._ __-.- D g ________ <br /> 1.;";I•CJi{tv1L l I'llAs.u7 Ale to App1 (1)' __. <br /> MCC•p7 tic v 03/1O <br /> SrP rtc <br />