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Illi ����o MARION COUNTY PUBLIC WORKS <br /> i11 �40j' BUILDING INSPECTION DIVISION <br /> m: <br /> e�%''1 �-- 5155 Silverton Rd NE <br /> no 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. N V 1 A It .c \c f e.A ,have authorized <br /> (Property Owner/Print Name) <br /> F/caw f inL CO6 3-k-+r'tic4 iO/) L. I-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 /> PROPERTY IDENTIFICATION: <br /> '3 Ca_ 5 S k A-5 '\o4c1 9&.i- eS' O( 110i t <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description .Ce.e. o - -&CLed tiocitA"4z "14- Tax Lot.#(s)Ogl-' E gJ660 ?QQ. <br /> PROPERTY:OWNER: <br /> Printed Name: 9Ol V i Gd S L w V-- F ez <br /> signature: Date: S"7 (, — < <br /> Address: a)•(3 w A4.4,4 r- f eo. b LI 9 ? Phone:co.? --13,-)."-?4s1 <br /> City, State,Zip S14,61 i *'f og 9l3 g ' Fax: <br /> E-mail Address %S d S Lok Y ceff(9 ,\- ( - <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: N6kbv \( .Q,AZi <br /> Company Name: to W\i (O►'IS1-,r,Ac.i-i'on L1-c <br /> Signature:, Date: S/l 1 ( 2 0 2.1 <br /> Address: i I 'O' S-61 S-1- Phone: <-0`3_$-7 I '22G 0 <br /> City, State,Zip S o.\P-wt O 9- 0(7 3I 7 Fax: <br /> E-mail Address Coi l-/t4c4-i`e m.-1o%.1)1;ne Q,q'AAA;i . co <br /> kil <br /> DEQ License# ?�c1t-ci { �l CCB # 23ai t-t9 Z <br /> G:WFORMS\SEPTIC1S-07 Atoll to Appiy.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />