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S3 f.° )&' e4q- <br /> �����,, "� MARION COUNTY PUBLIC WORKS <br /> 'III �1""' BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> mg„ Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Da le_ ,have authorized <br /> (Property Owner/Print Name) <br /> ife,.f KA w"(6^„r\ C u tr itEr+A'o to act as my agent in performing the <br /> (Authorized Representative/Print ame) <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 /> S I Fo(2.Esl-- 14AL,ch WAyS ,SA-ccr\ Oi 473o <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 /> Printed Name: p u <br /> Signature: Date: <br /> Address: ) T4%c' S r S C Phone: Ca I 3 7 a- Z S i 0 <br /> City, State,Zip -SA t_C'-\ 0 4 c1 )3/7 Fax: <br /> E-mail Address k/z ,r L_ 1La, {„tom <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 4_, / c_vi-ir 1(Z cn rtio <br /> Company Name: K'A u�.� -►-►..- / , <br /> Signature: 2CG— Date: ! o /1/Z3 <br /> Address: S) _ST SE- Phone: S o3- )0T-c <br /> City, State,Zip SA ��,� a2 c 7 3/ 7 Fax: <br /> E-mail Address kz'lr a'— xa tiF"�., At f. <br /> DEQ License# CCB # s S Y Z ( <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />