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r <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 555 Court St. NE Room 2260/PO Box 14500 <br /> Salem OR 97309-5036 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://publicworks.co.marion.or.us/building/ <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 4--tft_ ctrultic ch - !,/ g/q/ , have authorized <br /> (Property OwWer/Print Name) <br /> 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. I agree that any costs not satisfied <br /> by the Authorized Representative are my responsibility. <br /> PROPERTY IDENTIFICATION: <br /> G7c-l7 RSSck Ver,4:4) 12 q7 s �'I <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: nn e4 ocn-•i She ✓.ev <br /> Signature: Date: l 1'7 31215 <br /> Address: 17 4(0S I gty q O k Phone: Sa 3 9 e( j b <br /> City, State, Zip q 7 p Fax: <br /> E-maii Address Al tx S n e ;re1/0.1+0 A- a:I:C o►.'1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: We jebL v+ (. (A)1 15 O r1 -Se <br /> Company Name: LOn t PIYIL0 C-o+rntAr S ArC-S .1--nC.- <br /> Signature: C U) ,1,1 1\ 3)?. Date: <br /> Address: t COSCAtt ktADY Phone: 0O3—(?) 3- 45 <br /> City, State, Zip Silvwkan1 Cie, alb-'3bk Fax: 5t - 4;1-3-55 (4- <br /> E-mail Address t ovU ?JVWpsricS 4)111a.il• (OVA <br /> DEQ License# -Y-oo"-S CCB # J T-7-0CQ3 <br /> S-07 Rev 03/05 <br />