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; <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> • xr 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://wvvw.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I bracket Lc c. fu-rri s ,have authorized <br /> (Property Owner/Print Name) <br /> M a 1W CW G dwar c S 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. <br /> PROPERTY IDENTIFICATION: <br /> CloPtxcc Lv), l-yoos, op_ 'i135€' <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: Brct.6e6n LCL F04 S <br /> Signature: e '* -, Date: I0.2P 2020 <br /> Address: I l 164- 601v4ncr L n Phone: 503-.PO -1 SOU <br /> City,State,Zip 1-'1 n S, 0 ter,, q 735 Fax: <br /> E-mail Address fart IS. braAn.I �t) matI tom <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: k // IL• <br /> Company//: ,e: 1 • t i ti T �- <br /> Signature: , _ . . _ v...._ .._..... Date: < Z) <br /> Address: Z Phone:(S.Cc 3) <br /> City,State,Zip L/0y�- S q 733T Fax: <br /> E-mail Address TT kao s (3 uD 1) ' ,c a rl �/ <br /> DEQ License# CCB# 1 6j- 39 <br /> G:\FORM.4\SEPTIC\S-07 Audi to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br /> \ rktM . O ,1kst.l , (J'fr"f eC • <br />