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9---6,t a_95t, . <br /> ���� MARION COUNTY PUBLIC WORKS <br /> '��I '���ii''' BUILDING INSPECTION DIVISION <br /> ��1; 5155 Silverton Rd NE <br /> i-- . " .,. Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://wvvw.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, .3 a tet 1, Se.. 1w ,have authorized <br /> (Property Owner/ nt Name) <br /> k) ana apt" y c c_. e,_Vra.12. to act as my agent in performing the <br /> (Authorized(Representafi"ve/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 /> 29 Ta Z�- -.cQa) Mw Y E S€. --reg 9R 4 Z 52 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description/nap Q 30 A3 c Tax Lot#(s)/SDG, /4OU, /?0O, ( OC) <br /> PROPERTY OWNER: <br /> -"/ <br /> Printed N. a-: . . , ÷ _ t.Js,. <br /> ffDate:Signature: _ ___,,„„ - — <br /> Address• • - . S Phone: <br /> City, State, Zip .3te_r-yor) , UJ' 73,5-a_ Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ,o : d/Op J(5c.-, ws.m.ie <br /> Company Name: ej <br /> Signature: <br /> ARM, Date: 3-2f— /'9 <br /> Address: /ac) / �.�-r-r-e r _so et\ c. 9?E.. S C_Phone: i "/ - 9.2(- Ce074. <br /> City, State, Zips .e.rSo.t), OR 9 7433T Fax: . <br /> E-mail Address <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />