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MARION COUNTY PUBLIC WORKS <br /> • <br /> BUILDING INSPECTION DIVISION <br /> 2-if—CLOG-7 oG f°I2,14T <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http:/www.co.marion.or.us/PWBuildingInspec.ion AUG 23 2024 <br /> e <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 17j1. I I (110L- V )1/4..Pczvb J" have authorized <br /> (Property Owner/Print Name) <br /> IKx j OO i act as my agent in performing the <br /> (Au horized 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 /> I2 � T-13zS <br /> Property Situs or Street Address . • <br /> • <br /> Described in the records of MARION County as: <br /> Legal Description Pc ppy E51.L s La 1. 3 Tax Lot#(s) 0 9 3 w I / D OO.2 co a <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed N 'I ly \v cdv <br /> Sipa yam._-. Date: <-i -w?4 <br /> Address: $ S Nib ire( ST Phone: -57 4 <br /> City, State, Zip &A)21\�r�b-tf(8L Tibr S Fax: <br /> E-mail Address 10%1 -j Q-Fe szr,c kik- ,C_6,r• <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ( >• /c v-- L-`:x'e_ tea: 6 ti <br /> Company Name: /4 h /GPC,7 E>c- i <br /> Signature: Date: 8 -2-3-2 �/ <br /> Address: Ca 2 g _Cg. Phone: SO 3-q 3 2-0Y8 y <br /> City, State, Zip sti l�,.ti , 6 Q g17317 Fax: <br /> E-mail Address 7'&1(e-AUA7/0A)c ao/, co 14^ <br /> DEQ License# 3 ' 231 CCB # 1 C 5 8 �/g <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />