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MARION COUNTY PUBLIC WORKS RECEOVED <br /> tun: BUILDING INSPECTION DIVISION JAN 16 2019 <br /> 5155 Silverton Rd NE <<7 <br /> MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION(503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.onus/PW/BuildingInspection - c6 LI iv <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> OI t Wt A-i D L 2S o pi ,have authorized <br /> (Property Owner/Print Name) <br /> P6fc 'X.. rn o6 i f{ 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 /> pain cAL <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Nul/y 0+ Sec--9, TA/-Z/S R-2- o♦ Tax Lot#(s) R U C <br /> -- wll {}-t. Inneridrm,J E Marw,vto/ op.. <br /> PROPERTY OWNER: ` <br /> Printed Name: Lo!moi YV1 L L LS O/N) <br /> Signature: Date: '/z)/2/2 /.4? <br /> Address I-102_ t V t . . Ad: N ,t-, Phone: 59 3 —,S-3 y — z IPJ-9 <br /> City, State, Zip sq, Pcr u I / 0 Q cf 9-13 )' Fax: Sy 3-- 4 33 "Z <br /> E-mail Address Lor,a o(2"-so,,i 24 e,41 c.:I. (_c9-nom <br /> AUTHORIZED REPRESENTATIVE:, <br /> Printed Name: Pki4 L� 1405 itez <br /> Company Name: <br /> Signature: 6 �`^'' Date: <br /> 7 \ ( 12- Phone: 5 3 ^GQC <br /> Address: �^7��� � Pr � � <br /> City, State, Zip 52,14 ('` V(1— 1. 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 />