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ECE---�� + MARION COUNTY PUBLIC WORKS (� <br /> ��� '""(,,""� BUILDING INSPECTION DIVISION <br /> 11111111111111/ <br /> _�%�" �� 5155 Silverton Rd NE E n I <br /> A� ZQ � - <br /> Salem OR 97305. ' �aF31CJ1y -. }�,� <br /> (503)588-5147 Fax(503)588-7948 BUlLDIN r � ., � r ' <br /> http://www.co.marion.or.us/PW/BuildingInspection '�' {T IONI <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Rich Clausen ,have authorized <br /> • (Property Owner/Print Name) <br /> Katie Ryan 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 /> 8229 Jordan St SE Salem, OR 97317 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) 082w11A000700 <br /> PROPERTY OWNER: <br /> Printed Name: Rich Cla en <br /> Signature: Date: 4/2 8/2 3 <br /> Address. 229 Jordan St SE Phone: 971-218-6107 <br /> City, State,Zip Salem, OR 97317 Fax: <br /> E-mail Address raclausenjr@hotmail.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Katie Ryan <br /> Company NaI ►e: ethel Excavating <br /> Signature. Date: <br /> Address: PO Box 504 Phone: 503-743-2343 <br /> City, State,Zip Turner, OR 97392 Fax: 503-743-3638 <br /> E-mail Address officeRbethelexc.com <br /> DEQ License# 36198 CCB# 44551 <br /> G:IFORMS1SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />