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JP11l v v ivi e <br /> RECEIVED <br /> MARION COUNTY PUBLIC WORKS JAN p 91024 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> 11111114 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://wwvv.co.marion.or.us/PW/BuildingInspection <br /> ,� <br /> (NOTICE AUTHORIZING `REPRESENTATIVE <br /> `I, low\ M itc.A vA 1.h�.e5I ,A,Ts- LLG , have authorized <br /> (Property Owner/Print Name) <br /> War rev" Loe(-vt 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 /> 60.60 Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description , „;, 0 4 1 W 18 B p Tax Lot#(s) Rii-4414 <br /> PROPERTY OWNER: <br /> Printed Name: p& \A L ' Two e S- oNd eA LLC, <br /> Signature: UAjv%,Gi^. Date: \ 16 i v- <br /> Address: 1n3'1 �C�v� C�a.N. LA Phone: 503 5o2. (o0(0—S <br /> City, State,Zip St0,14o.e% p 1 ° 1?jb-)j Fax: <br /> E-mail Address Cv" ;Vv-c.4wv rt . WV" <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: (Ak .re h koe k+) ?3 go,tirv, <br /> Company Name: 11 en it a a Soo <br /> Signature: Lit-A---‘ / Date: <br /> Address: 3,D,Th -4}y,,y aa, Phone: 38 - 1� <br /> City, State, Zip sc;p 0 1k 3 1 y- Fax: <br /> E-mail Address (pep hn @.,(1 6 wit-nt-I- coin <br /> DEQ License# 3W6 4-1-‘ CCB # 1?5-j�1+ <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />