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23 -00-7 /6 PRAT <br /> 1 <br /> �'�� MARION COUNTY PUBLIC WORKS <br /> ���� "'" BUILDING INSPECTION DIVISION <br /> —��%�� �� 5155 Silverton Rd NE <br /> r Salem OR 97305 <br /> MI (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> i <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Fe<-1 y'q A l q'tve_e_✓ have authorized <br /> (Property Owner/Print Name) <br /> t),f Un?i a ee(/ 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 /> i810jcf A-rfor C-713. Rd, ,Vj &dadha ' , OR, 9707/ <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: • <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: Fe pi y of 114 7LUetoV <br /> Signature: � f%j/.Ey,/ Date: %C-Zoz 3 <br /> Address: /g(3 4r4& - (1 yo,v,_ /6/. JJ Phone: C6 3-752_-73 7 7— <br /> City, State,Zip “c>c VvA-\ Q2 . Fax: <br /> E-mail Address 24;',..y q vy)a 4r e 17 p3 psia/r/, c Gam, <br /> AUTHORIZED REPRESENTATIVE: <br /> // <br /> Printed Name: �n 7'�l n/r /114 e t l/ <br /> Company Name: <br /> Signature: --- Date: ?-6 0 Z 7 <br /> Address: /rk I V� Phone: <br /> City,State,Zip kAhd dc' Dz _ 9707/ Fax: <br /> E-mail Address q'h7%vt/hq7-/ecrad t 0%Goy-, <br /> DEQ License# CCB# <br /> G:\FORMS\SPPrIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />