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otr"''"v.-^M1,- <br /> ` isumpi1Vu INSPECTION DIVISION <br /> N- ry�� � 5155 Silverton.Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.eo.marion.or.us/PW/BuildingInspection. <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, i' - - ar e Z have authorized <br /> Ai, (P o erty wner/Print Name) <br /> e 1 d I a.s I r I OOCc J?o K.Z Wi s 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 /> r 755 T 1 #1_ LA/ N WoodioUrrlidF- 9707 <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 /> por e.l- 05tv1098 ooqoa-pr-ivhal-H <br /> PROPERTY OWNER: <br /> Printed Name: /�� l a cAp°'2 <br /> Signature: <br /> Date: 9— of -aa. <br /> Address: I 3L/ Coo Cd. Phone `J- 03-°\ J-_ 1 (QU I <br /> City, State,Zip 004.bif r\ i0E- q-707/ Fax: <br /> E-mail Address./1/q,-2-;-/-�Sk vie.I.. 65. <br /> ATYTgOR DREPRESENTATIVE: <br /> Name: J1/ kô <br /> 1 --S Mcrca��- / .mot 0pruned <br /> Company Name: N K £Xc a.va d L._-L C <br /> Date: q- az - v�� <br /> Signature: -Address: _ <br /> 765( \AJ - 'A V1-� ga fife_ Phone:550 3 — Q 9— 1 o . <br /> City, State,Zip Sti 1.eYvk/ or- c1 7 3 OS Fax: <br /> E-mail Address ►.0 ko Lc'S Ka-vn 15 6\,Mtift .y <br /> q y►^- <br /> DEQ License# 3 COCat CCB# d3R 59 7 <br /> G:IFORMS\SEPTICIS'-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />