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l <br /> ���� MARION COUNTY PUBLIC WORKS <br /> '111 1jgit"'*. BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 • <br /> (503) 588-5147 Fax(503)588-7948 <br /> http:/iwww.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> rY) k 14 c.yi4 L have authorized <br /> (Property Owner/Print Name) <br /> Lit'14 c✓ 6,44„4,,,„ LLz 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 /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) '10a <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: \'<G -\ L- . <br /> Signature: Jk � Date: ' 2 O-2-3 <br /> Address: e 0 pp 9 qq (zc1 o � � 3 <br /> O X 1 r( C1 2.�o et19(PR2� <br /> one: !-6-zs r7 <br /> City, State,Zip 5 /L U e t i V--/ 6 t2 -7 3 g C Fax: <br /> E-mail Address N �� 1 (C s e M C O 1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Ala, it 49 J <br /> Company Name: /AA- o V d i �✓�k <br /> Signature:"Id,- Date: <br /> Address: Po 66, 6 7 Phone: <br /> City, State, Zip dn134 v. Q• 17 3(e Fax: <br /> E-mail Address Gj;/ Ll.c 2 t e.s •c..6 <br /> DEQ License# CCB# 2.3 5 3°) <br /> G:\FORMSISEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />