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• 4 <br /> MARION COUNTY PUBLIC WORKS <br /> • BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Sales: OR 97305 <br /> (503)588.51.47 Fax(503)588.7948 <br /> http://www,co,niarion.or.us/.l'W/I3ulidin Ins pecfion <br /> I; I <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> .-- ]/� J f <br /> � 1 .r ,r f <br /> a <br /> n 1e, <br /> I, a. • � "� i 'v <br /> ,�auttlorizcd <br /> Property Owner/Print Name) <br /> d c 5 4 J-d r < 4 ae,v2 - �� ir: 1--1.4 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 /> 7 if.14 Amd2.1 <br /> y6s o Street Add,et i o e 73d <br /> Property S <br /> And described in the records of MARION County as: <br /> Legal Description 06 I GI/4 ( Tax Lot#(s) OO&d(7 <br /> PROPERTY OWNER; -b//i/7/i) �t.Lnati / f <br /> Printed Nam' <br /> e: IId I ._ f I i Lr. '_.L U Til <br /> Signature.. /(,1 L' Date: Q <br /> Address: 75'7, rL 4,5 <br /> G Phone: 563..`7`7 ? <br /> City,State,ZipkiVA,VOle, i , 1 Fax: <br /> E-mail Address• Y&/- inh/tJ oN(?J @ ry ;-.P'04yy1 <br /> AUTHORIZED REPRESENTATIVE: J JZ vi.�b <br /> Printed Name: J eSv 5 AviLt cyd+ <br /> Company Name:_, , e. b u P JD v►, _ L• <br /> Signature: Date: 6 /SP 9' <br /> Address: /( % //a,r v e y S � Phone: 9 71_01/ 3S`64 <br /> City,State,Zip e r 5014 (2 7 — Fax: <br /> E-mail Address i,06 tql. oreo C. <br /> DEQ License# 39' 0`0 A CCB II > 7,r9 <br /> 0:1FORMSISEPTICIS.07 Auth to Apply.doo <br /> MCS.07 Rev 03110 <br /> SEPTIC 4 <br /> L <br />