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0 q- bt Lr73-43 <br /> - - -_ __ RECEIVES <br /> mmtioN couNn, PUBLIC WORKS <br /> 111'11.DINC INSPECTION DIVISION <br /> • <br /> AUG 12 2024 <br /> �� ��' S155 Silvcrton Rd NE <br /> iiii Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> litip://wnw.en.marion.or.us/PW/BuildingInspeclion <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I. t .j)�z+l t) -d0 r11Z.l_15C.}L� have authorized <br /> (Prope4 Owner/Print Name) <br /> Josh Hansen (Oregon Sewer&Drain LLC) to act as my agent in performing the <br /> (Authorized Representative i Print Name) <br /> actin itics necessary to obtain site evaluations,permits,and other onsitc 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 /> ` }46Ir 11t-A-nac-a- Lv V.+L <br /> , Si 1Ve vL C 3E''11 I --— <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description_ _-- Tax Lot iI(s)aki W_2!b _6Oi n O <br /> PROPERTY OWNER: �/ <br /> Primed Name: NQ 1 I '4 Kl j�—�1 <br /> n rJ a rcc e r k_ = ---- 1. <br /> � Date: o/` <br /> Signature: )' a-7 _ _- — <br /> Address: �y��t'�.._,Q�+ �t- - ---Phone: `.76�j�`�`) <br /> City.State.Zip ��I i ve Y k n" C2 T ---Fax: I I <br /> F.-mail Address �I►��-}-t Ir11 O�c��I'1�C' <br /> rl mari)� cCW'. <br /> J c i <br /> AUTHORIZED REPRESENTATIVE: 1 <br /> i <br /> Printed Name: Josh Hansen 1 <br /> Company Name: Orego Sew Drain LLC ! <br /> Signature: Date: 5 6 •?y• <br /> Address: PO 2 Phone: 503-874-9414 <br /> City.State.Zip_ Silverton, OR 97381 Fax: <br /> E-mail Address_josh@oregonsewer.com <br /> DIX) License 4 38968 CCB II 201683 <br /> 0 1'W'dti 11 V I IC)-1,7 Atoll I,.Apply 1 <br /> ?!' -01 Rev 03/10 <br /> ':l.l,r V; 4 <br />