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/y-0037c5 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 555 Conn St]1'E/PO Boz 14500 <br /> :.= Salem OR 97309-5036 <br /> 3 <br /> FAX X(5(503))58&7588-7 <br /> 948 <br /> www.comarioa.or.n _I <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 6544tra Fin+1y LLQ, /CRkici d VRur! \l/,Itti , have authorized <br /> � l (Proderty Owner/Print Name) <br /> Att r e L J . /`5' 1.14S to act as my agent hi performing <br /> (Authorized Representative/Print Name) <br /> the activities necessary to obtain site evaluations, permits,and other onsite wastewater <br /> treatment program services provided by the Department of Environmental Quality or County <br /> Agent on the property described below in accordance with OAR chapter 340, division 071. <br /> I agree that any costs not satisfied by the Authorized Representative are my responsibility. <br /> PROPERTY IDENTIFICATION: <br /> 71t2. E t, s . NF <br /> Property Situs or Road Address <br /> And described in the records of MARION County as: <br /> Legal DescriptionA,siva Qrooe•[arIS Tax Lot#(s) 123`f1,005 <br /> PROPERTY OWNER: <br /> Printed Name: . . LC ° Ti t_ <br /> Signatures . �{ at Date: 5/2//12 <br /> Address: o R "9/ Phone: 503-`,32-aro¢ <br /> City, State, Zip £s-vreiv,0 r 97?6l Fax: <br /> E-mail Address rn////an+e-11e aft5rr.i%1 C• d_yairrm• Co..l, <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ThAnI(1 S • "6 s I <br /> Signature: .4()a,.r..OJ n*a_ Date: S/�3`/� <br /> Address: I4// ,�7 r'` AVE. Auj Phone:5e 9/e —,9/v' <br /> City, State, Zip :5/San? / On 97 304/ Fax: <br /> E-mail Address cJa j4o4s n-bi n. Gbvh <br /> S-m Rev m/05 <br />