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MARION COUNTY PUBLIC WORKS <br /> '! BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, S. SV112-t1€x' ,have authorized <br /> (Property Owner/Print Name) <br /> \(\��� S�Q�*\�,1�' 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 /> 4i2Lo &\O \ c D D \mop \ .) c*t5 M\\\S t OCZ C\ "5 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description NQX1a.S 5,Cn) MS --- (Do\gG,S1()), Tax Lot#(s) 011E 01?) oospio <br /> �torc,>z 25 - 22 <br /> PROPERTY OWNER: <br /> Printed Name: ( S\c,Q.±l-e5c- <br /> Signature: d1`%s.€__ ��. Date: 14-- 1 - 2C1? <br /> Address: /0 ? O)C, k-\y412.10 \:2-$1'\(IS' \4\-\4-) NE Phone: 2l°\ct <br /> City, State, Zip ao N'\\\s, 9_ c\--\?l5 Fax: <br /> E-mail Address Sr(S\v_ \t2r@( mi \\. (orr <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: \`<`r\ <br /> Company Name: <br /> Signature: Date: 4^ (O 1 c`( <br /> Address: `P 0 BuX LN-A-1/41 x, V2-3 \ ) - unO'O LP NE Phone: 54-2)-gS 1- <br /> City, State,Zip Sco`Gc5 1\A1\`S , OF_ on-pp- 1CD Fax: <br /> E-mail Address J IV tL c PX'@yr cU `a c rn <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\5-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />