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• <br /> �,, MARION COUNTY PUBLIC WORKS <br /> '��� "'� BUILDING INSPECTION DIVISION <br /> MN <br /> %�� �� 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 055 T. M 1 t t / DD Y1 1 L . 1 i V ,have authorized <br /> 11� (Prop rty Owner/Print Name) <br /> fl ,� <br /> ol727pSv,, //p Sof) S.e"-WC.e� i LLC, to act as my agent in performing the <br /> (Authoriz d 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 /> 35y2-5 Si- 5 Lo,-'s, (o,^, ��3 6� <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal DescriptionZryA/ls ,L/k1 se.,b/ 6 3 l L Tax Lot#(s)Og 4/C 3z a Or)3/00 <br /> PROPERTY OWNER: <br /> I f nn <br /> Printed Name: R,s ' ((lie - 2, Dravt� L • Y Y `l t l°iv' <br /> Signature: f^�-' " Iti 0 I c te: Z./1-7/MU <br /> Address: 1 55 5vv i(;l.Wl.VylEJ,/' Phone: 5O -cRgl `14 Z f1 <br /> City, State,Zip Tqa yd , OIL 01-7223 Fax: vl/A <br /> E-mail Address (,1(1 ( I I Y 1/1(51/41,—Cir e O 1 . l_6YYl <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: !.-,?b 10ps477y <br /> Company Name: Aps,.,,-7 S-rvtce-5 1 LLC <br /> Signature:"' f?---- Date: en21/5,/,7_,mjj <br /> Address: Ao 8e9pc </ Phone:5o3 8 lit 4/ <br /> City, State,Zip/LI/// c-/ , or- 97 6 Fax: <br /> E-mail Address r��hps € ,te,°l, ccm <br /> DEQ License# 3 92_2_ Z CCB# .4i/K%" <br /> G:\FORMS\SEPTIC\5-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />