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ti <br /> ��,,� MARION COUNTY PUBLIC WORKS L <br /> n��'41� BUILDING INSPECTION DIVISIONC 3� �- <br /> ��i � 5155 Silverton Rd NE yr-O)Salem OR 97305 <br /> MI (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Al 1 k116 1 i i�p v rk1(:)4J‘& , have authorized <br /> _ 11 (Property Own�e�j�/ rant Name) <br /> 4r�-tZv PIMu-�,(1 to act as my agent in performing the <br /> (Authorized�Representative I 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 /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: II• <br /> Printed Name: rvi 1 k�/' kpVa ickLt44. <br /> Signature: x Date: <br /> Address: 261 II P 41- •P Cf /Vliti Phone: 12/ 7 /do 2p <br /> City, State, Zip S' /€oft o P g i 3(0 Li l Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE:: �i <br /> Printed Name: ,,9,4��,rny s4i P-kJ <br /> Company Name: <br /> Signature: at_ 1,1 4 Date: /2- 9--2o.-O <br /> Address: 410 6 R6///•t-H; DA JCi Phone: 03 t,3.3 0066 <br /> City, State, Zip <br /> u'�n� � ��. ?)��rr 3O�ti Fax: <br /> E-mail Address ,9R,�P y/namej.2Tr' �9/YTA,L.60,11 <br /> DEQ License# v CCB# <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />