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.,,� MARION COUNTY PUBLIC WORKS <br /> �ii 1j��i�"''� BUILDING INSPECTION DIVISION <br /> --��l`7. 515155 Silverton Rd NE <br /> ,ga,: ..,- "c q, Salem OR 97305 <br /> (503)588-5147 Fax (503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Aft t 6 /1,"c 5o ,have authorized <br /> (Pro Ow r/Print ame) <br /> — <br /> 6 � \,�y` 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 /> CASO 5 Aurt i\\\P- \\' \1\\ ,'y� St S a\,e,rn Ori._ 3 VI <br /> roperty Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 0 o�W\bWn o0 Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: ASc5 //, a(4/.,p <br /> Signature: Date: 0 g— is- — 23 <br /> Address: 3042 2 art o o 2-c /,,.,? ,4ta -e Phone: ci✓3 26 t <br /> City, State,Zip S eyy,) 6 irk '1-3 D:S Fax: <br /> E-mail Address RA, y A WA,7) >'h 6//c OcAyi i If,, G e 7-a? <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: "0OM GJ e ('0 <br /> Company Name: • - 0. \nil U_C <br /> Signatur : Date: e•--te-go2z <br /> Addre . 11395 51.3 Aryl\I l 'Irk A, QE- Phone 5Q3)15-6 ' <br /> City, State,Zip 5a\ e_ 1 l30 5 Fax: <br /> E-mail Address ClR esc.Cta31a\.O®th CO f <br /> DEQ License# 3614 CCB# 93_)ir 6 <br /> G:\FORMS\SEPTIC1S-07 Auth to Apply.doc <br /> bICS-07 Rev 03/10 <br /> SEPTIC 4 <br />