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RECEIVED <br /> MARION COUNTY PUBLIC WORKS Ju% 14 202k <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> rt) P c j us 1,•ut <br /> NOTICE AUTHORIZING REPRESENTATIVE Doi <br /> I, C,c,i,e_.i,�Lc iut4;I r�9,/5+ / STD try Co 1 -1 & t-yu have authorized <br /> (Property Owner Print Name) <br /> Lev 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 /> 1°S1 S-(-ahLil-t I S 5 13 l�' �a 1Le elfirvaxis Ovc_. <br /> Property Situs or Street Address '1U <br /> Described in the records of MARION County as: <br /> Tax Lot#(s) <br /> Sub4;vdcinn, T ot-a„ lock <br /> PROPERTY OWNER: <br /> Printed Nam : lti� C' CJl{ifvLa.)'t_ 1 mar(itS+ Breve- <br /> Signature: Date: PM 2 <br /> Address: I gq Ile- kit Phone:q/3181.7 ;; o( <br /> City, State, Zip C--t►r`Nr (TYL-r Cj�o�L Fax: <br /> E-mail Address S'r'(6,61 I/to k ( a o ' Loll <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: '/ <br /> Company Name: <br /> Signature: Date: - <br /> Address: 'Zg�1 &�-+ t� Phone: 5i)-3. O • $3�. <br /> City, State, Zip 6-reArkle .s OY- c i u210 Fax: <br /> E-mail Address-f u 18 (/ (. <br /> a 1 - e <br /> DEQ License# (1 CCB# <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />