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00cl/sign Envelope IM 91F21BEA-7801-416F43MA-1328D303073F 1
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<br /> C104111,61 MARION COUNTY PUBLIC WORKS
<br /> EC E NE*
<br /> A .......--, BUILDING INSPECTION DIVISION
<br /> 2 '
<br /> 5155 Silvertort Rd NE ' 7
<br /> .......m„.......— ••
<br /> Salem OR 97305 JUN
<br /> '.4 588-7948
<br /> (503)588-5147 Fax(-c03) 2, , 0 2024
<br /> ,,r http://www.co.marion.orAts/PW/BuildbigPOPeeIlon
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<br /> NOTICE AUTHORIZINGREPRESENTATIVE
<br /> .. oean KIrkpatrick and James Kirkpatrick
<br /> have authorized
<br /> (Property crawler/Pi-int Name) .
<br /> arl._______7__- __-:' to act as my agent in performing the
<br /> i (Authorized Representative/Print N ) 7 ,
<br /> Iciiviries necessary to obtain site evaluations,permita,and other onstte 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 I)ENTIFICATION:
<br /> 49690 N santiam Hwy N, idanha,OR 97350 Lot 23
<br /> • : , Property Situs or Street Address
<br /> ? ,
<br /> i And described in the records of MARION County as: , : : .. .,:'
<br /> f ;i, 556307, 345488
<br /> Legal Description . Tax LoOcka)
<br /> PROPERTY OWNER: ..,- :
<br /> . nean"Kirkpatrick and James Kirkpatrick
<br /> Printed N . Nnedbr
<br /> Signature r*--apeuSk 41" in Date:
<br /> Qr;
<br /> RAJA, 4ivtilitlyitia - - 6/5/2024 I 9:19 AS/9112024 I
<br /> 44.2,„.„..,...
<br /> Po (3ox 412, Lyons , OR 97358 ' Ph-Oile:Dleamane5°S30-35-r16-3-9674741
<br /> Address:
<br /> city, State,Zip'
<br /> hiazerdean@pompavp.pet ,
<br /> E-mail.Address .iimIci02241@aol.com -
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<br /> AUTHORIZED REPRESENTATIVE:
<br /> , _
<br /> C'• i ,
<br /> Printed Name: bil tt-I-uptivi, (N6,4 e t c 117 il :
<br /> Company Name. -,. t VC, n.—, 1 tevt• .,
<br /> 41 '
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<br /> Signatufe:'„.
<br /> Date: (.0 -k. -2_4
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<br /> Address: le0 601— 2At SO Phone: 5133-3e;t 0-to zi 3 tst
<br /> City, State,Zip 1 00— 0 Fax:
<br /> E-mail Address uo,kk (.40"...5 6) 0,,),-er...4..lit‘,„Syg, 0..,.._ --„„s..t. .
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<br /> DEQXicense 4 scsis--.3 el CCB# 1 Ls)ST 21-0 I
<br /> alF91L),1,..,SSFX110,S-07 Auth to Apply.doe
<br /> MCS-07 Rev 03/10
<br /> SEPTIC 4
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