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1q-- 0030 12- Avrl <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> 191C15-NrF: <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 '_ _. APR 2 5 201 <br /> http://www.co.marion.onus/PWBuildingInspection 61 <br /> M-is-tioN COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, -coLAN c3 C> ,have authorized <br /> SU 'roperty Owner/Print Name) <br /> Q( — \J&�{' CLS to act as my agent in performing the <br /> (Authorized Representative/Print Mme) <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 /> 10S-7 mai it k 1c sT, RiAnkco ( 14_ O1 973as— <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description (AV w 3 a 6 O l(0 0 D Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: 1'.cci.: . C V\ <br /> Signature: ' Date: 11-10-1 <br /> Address: I0S7/4 i'Y? !^ t',P.o�� �� S <br /> Phone: <br /> City, State, Zip ft(AIV V t t IQ_ ) )R (4732S— Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: J e. FD X- <br /> Company Name: �l <br /> Signature: v_ — _ -A Date: 4/—/t) <br /> Address: I C�5 7 ' mill � r-vg Kat S . Phone: 47,5--33O- q 7 l Z <br /> City, State, Zip f u yv u l I ).P L9 t1 a 73 Z S Fax: <br /> E-mail Address Sue , fox @ n0 q j l C O nl <br /> DEQ License# CCB# <br /> G:VFORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />