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" Salem OR 97305 �.�j- -O6�ISS- E� L <br /> 1111111/ <br /> (503)588-5147 Fax(503) ingIns48 - -/] <br /> www.co.maxi®n.or.a�s/PWIBuildin�Insoection LI V <br /> En <br /> MAR 252019 --i--. <br /> NOTICE AUTHORIZING REPRESENTATIVEdtigrINVV1871YONc� <br /> I, .6.74 4-U 4. ,„ t It -P 4�- _ J.* c_t�� C TJQ IGve authorized <br /> (Property Owner/Prim Name) <br /> On-Si1 r c F(('1U akti a r`s to act as my agent in performing the <br /> e <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 /> C7aE. aD iA. 00400 <br /> Property Situs or Street Address <br /> And described in the ords of MARION County as: <br /> Legal Description Tax Lot#(s) , <br /> PROPERTY OWNER: <br /> Printed Name e \ A 4 Net j tt. poo-(A-- )v d-► r L. Z <br /> Signature: `` v y_r;v� ��pb, Date: .3-a- t'l' <br /> Address: c E>:?-3 ,1, 7 7 .JNek 7-31�etii(G� O .. Phone: sly/-Z7O'- WV/ <br /> / <br /> City, State,Zip 2`;uar�-\>�ldw,ucc,- 0,2: 9730Z_ Fax: <br /> E-mail Address J h i c_-kS,( i- ,`(, & t-1, <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: • • e1)v-*qd <br /> Company Name: Qv - 01 �/��-I C 1 eYC GI UCC,4t cry\ <br /> �' r Date: 03( 1 C, fF1 <br /> Signature: . / �, <br /> Address: , ( (5. 1;:;;;: sa4 l Phone: , --P1.3 1-2-7000 <br /> City,State,Zip s ‘e0---) 1 OR 9 73o 4 Fax: <br /> E-mail Address OYl511 ')d In I I In e n w• .CCY - <br /> DEQ License# '78, CCB# ((-)C4 4 <br /> G:IFORMs1SEPTIC1Appfic ation Packets1S-O7 Audi to Apply.do= <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />