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1 <br /> • <br /> "*.• , <br /> PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> • <br /> — <br /> MARI°N51C5O51:e:tan IId NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> [Illing111111.1.111. http://www.comarion.orms/PW/Buildinffnspection, <br /> NOTICE AUTHORIZING REPRESENTATIVE <br />.., <br />, k s 0717/9Pia . 7.?4.L.er7)rei7.7-- _have authorized <br /> (Property Owner./Print Name <br /> --..16'.55 ts :Se.v141 r AO;efil ilietrill to act as my agent in performing the <br /> . (Authorized Represeni,ge/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 r <br /> k 7s-Zi) 02:,,(9yez) aii`,.. 6'6-- <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> k Printed Name: 1,9i/ae'‘e /6 eXt12/99e42),C7- <br /> Signature. . ,... .• . ..1-7- ,'gaP Date: et0-' /;/ <br /> .• It" <br /> Address: ' Z.5.--,,//),1) 9,e,-) .477/, ,s-, .. Phone: 77j3--,,c-4141.,7/...S..5/ 4.\e• ' . <br /> (I-City, State,Zip c\52,4 t4vi.7),) iM 9. ,.T./1. Fax: 7 <br /> cr E-mail Address i92/7,,//e0/99e402e/7,fi /V <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: , ‘ -e 55 K. 1 e..../9i4firig <br /> -./ <br /> Company Name: •4,4,,,7k, 72,-,, <br /> - - . <br /> Signature: ' Date: 7/014: <br /> Addres . 0- - p hotte: a 3- ?31-,2 I/eV <br /> city, State,Zip 5 tz/e km i 0 773/7 Fax: co 3- 515- k;o9 <br /> E-mail Address jr. a c-i-ion"'vi 3 Ai qd. cool - - <br /> DEQ License# 3.1(32.3 CCB# ' 50/7/ <br /> C4 xFORNISSEPTIC\S-07 Auth to Apply.cloc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />