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t��� • MARION COUNTY PUBLIC WORKS <br /> ''w <br /> o <br /> ��I "'' BUILDING INSPECTION DIVISION <br /> „,,,---7-7-7,1,-,c............ 5155 Silverton Rd NE <br /> '" Salem OR 97305 <br /> 9P-°291V-- -714Q7— <br /> (503) 588-5147 Fax(503) 588-7948 <br /> www.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, .(Ct:) 5 ' 'i -7- ,have authorized <br /> (Property Owner/Print Name) <br /> 7`LO -uktku/-Si e.[<11_-c_ 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: 4 _ <br /> Y92 - set, , �� <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s)r05; 1Z3 0; 5'' c D 0 <br /> PROPERTY OWNER: cf 3 00 <br /> Printed Name: 01.4,Tt-Kc—ce-9 6 wax <br /> Signature: Date: `-/ / 9 //5 <br /> Address: 27('7 gef,c 0 Lou, /29 _s Phone:0.03) 31 - 5-766 <br /> City, State,Zip 6,4,..t /®2 7yc9 2 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: oicm 13 I G{,/l.LA. <br /> Company Name: <br /> Signature: �7/cc �t # 4 I Date: 4f —9 —2,(-9) dl <br /> Address: 23/,_ � Aoc 6e 771 6-4 fate 01- Phone: 5V3)57 0/7yL <br /> City, State,Zip 6ta2 9' �f 7 /� 3f 7 <br /> � Fax: <br /> E-mail Address A b,c . f< 0,a27 /1--6 -. GO <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />