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DocuSign Envelope ID:Al779F7D-2408-4FE7-8B67-13003D049DC4 <br /> Afflt1/4,,' MARION COUNTY PUBLIC WORKS oZ�_ t ,F.�� <br /> ```� "' ��;'"`"+` S:U1LD1NG I SPECTION DIVISION '"1�Y <br /> --• �� �, : 51 SS Silverto .Rd NE' RECEIVED <br /> IIII. max ` : -Salem OR 97305 <br /> (503)588-5147 Fax(5O )588-194s JUN 131014 <br /> ` hfip:!/www co,marion.orausiT WIBmidmglnspection, 'III <br /> NOTICE AUTHoRJZING REPRESENTATIVE <br /> 1, ()Weil al% :Vonxnc-. t iu`Vc b ,have authorized: <br /> (i1- ,, Property Owner/Print Name) <br /> (p OVI LSiifutOZn to act as.my'agent-in performing:the <br /> (Authorized Representative!PruitName) <br /> activities necessary to obtain site evaluations,permits,.and other onsite wastewater treatment progrant <br /> services'providedby die Department of Environmental Quahty'or County Agent on theeproperty <br /> deseribed.belloui in accordance with<OAR c apter 340,division O71,, <br /> PROPERTY IDENTIFICATION: <br /> .. Ul5c(0 Viv4e l..1.13rt ..14'l 56 . 5'VU(e,, bg, 'f ,i5. <br /> Property..SStizs.or Street Address <br /> ,Aria described;in the records;:of MARION County ass <br /> Legal DescripttiOn. O42, 11;D Tax Lot:#(S) a I(.60 <br /> • PROPERTY.OWNER: • <br /> Pxiatecl.Naane Dtthiqk, ` <br /> °' 6/6/2024 <br /> SiPatlIr �okua kt°6"- 1 Date; <br /> Address. 011itii .` Phone.. 03. 1(i1 1{1413 <br /> City,State,Zip Pax: <br /> E-mai€Address: aCtlkkttilt40 tl 'c t0 as• Cklict <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Pi i1, fr Olt tot- i J t (= t <br /> p iAt rbt ( St-vv <br /> Com anyN e� . <br /> Signature: Cuw� r. Date: ti t <br /> Address;,: Y, It 1 _, 4(PO -cavtinuelmiS St= 5,6: . .Phone: 0 41tL -`- / . _ <br /> city,8tiate,Zip i O 9 0' ' Fax <br /> :E-mail Address C, ittilti+Z CAVItt Wit w <br /> DEQ License:# ._ CCB'# t 1Zto W <br /> QAPQRMSVSEPTXC 5=07 Auth to Apply doa' , <br /> MCS O7.Reu 03/t0 <br /> -SEPTIC 4 <br />