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V <br /> II,a11'` MARION COUNTY PUBLIC WORKS <br /> � BUILDING INSPECTION DIVISION <br /> """ "�--'%,� 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Bnildin2Inspection <br /> r NOTICE AUTHORIZING REPRESENTATIVE <br /> , �` L VM WOO Cf ,have authorized <br /> (Property Owner 1 Print Name) <br /> i ,k ecSr_ns FtWiricirip Pee�v-sc)y-) to act as my agent in performing the <br /> (Authorized Repres tative/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 /> vE)(2_,av <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description .i oc tt 3551 Lc, (p Tax Lot#(s) cj L&)'35 cc 5CR <br /> PROPERTY OWNER: <br /> Printed Name: cS(j i �`[ ..C. l�d <br /> Signature: `eL,' ... �� C� { -,..0 Sep-20 202I 9:37 PDT <br /> . ' / Date: <br /> Address: /q .) ( X''f G ��. �1�1L�d,r' 's.fit i�j Phone:,r , g 1 c2 ' <br /> City, State,zip ( u k.)��' "`�t"'1�.-_ (�` — :,�axSJ <br /> S <br /> E-mail Address c,SQ t�1di rf e t woo& ' h t) A. s re o - c ryn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: -- e.t„Ser, rt eyscy--, <br /> <.:"- Company Name: A. PA,C+t'SCX1 c, ?to,n,�6 ass, ly-1 . <br /> ,, ignature: ��j�.�;�.._--- .,,,.,.:�, Date: Q-,, e9-‘21 <br /> ddress:` O 1,�c la p� Phone: � 3- 3 •3 <br /> City,State,Zip ~��t�...r� 9 73--5 (�(� � Fax: <br /> E-mail Address a.... eft- ©n a_ <br /> DEQ License# .361 I (n-3- CCB # ) S'O y .J — ___ _ <br /> G FORMS\5E19 J \Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />