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`'�a,, MARION COUNTY PUBLIC WORKS 03- b 71 <br /> t`I l a BUILDING INSPECTION DIVISION D L� n S - <br /> -i� �� `, 5155 Silverton Rd NE C-I V I <br /> .m' Salem OR97305 U <br /> MN (503)588-5147 Fax(503)588-7948 MAY 15 2023 <br /> http://vvww.co.marion.or.us/PW/Buidinglnspection <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 1 15 N till 9,i,rer t2 r3 LL(../ Cite n K n+ ,have authorized <br /> (Property Owner/Print Name) <br /> :\iv', -oY1 is ovn M ue;_kior Inc.!brrr Cli nto 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 /> /Da e Certfrcli ttre, Gate5102 9731- <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description ' Tax Lot#(s) ()Ci$E A t0 C;Co"a t0O O <br /> PROPERTY OWNER:. <br /> Printed.Name: <br /> Signature: j x ; �� Date: '1 f to j; 3 <br /> Address: t/ 1/7 , 5 a fe 54- Phone:50 3 Q3a e74d5 <br /> City,State,Zip Salt nl, D 1z 3'7 301 Fax: <br /> E-mail Address 'Jerte ICt;n-i" 94 hoo.Corn <br /> 9 <br /> AUTHORIZED REPRESENTATIVE: <br /> A <br /> Printed Name: &re. , CIin+On <br /> Company Name: (OA -Ofl CohS Toc,t-itar, Inc <br /> Signature: �l/ Date: 11/2 u ia. <br /> Address: 'jCi/(14 mon-}-6pyr_re j r Phone:50 j 0 i 1 Ii'i l,G4 <br /> City,State,Zip Sc.i 0 , pit Cu ./1 iLi Fax: <br /> E-mail Address cycle .c.1i Al-on(. 1,3tAY10O.Gclrt1 <br /> DEQ License# SG1(Jti 0 CCB# A1,45/L/9 <br /> G:\FORIVISSSEPTIC\S•07 A th to Apply doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />