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o <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I <br /> I, oh r) . 06 f7t <br /> ..._ ' ✓4tilf) have authorized• <br /> Vi (Property Owner I Print Name) I <br /> /(//4 r_94 i''- t C:5 elis t-- _ to act as my agent in performing the <br /> (Authorized Representative I 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 /> Ed `& '/7317 <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: �J5?-4-5 766) G`YO, <br /> Legal Description. 27 Tax Lot p(s) ,,_ ..._ <br /> Subdivision.Lot and Block <br /> PROPERTY OWNER: <br /> Printed Nams: ) ;'C`e - Pr-4;9 e d : 17 4 t-1=2 c� t. €1:?5 <br /> r <br /> Signature: ,,�� ».. — .. _Date: i/l 9/ <br /> —58''' .-3A� t-,)-- Akre vis 1 c c Phone: :'C,-.5 S/-.3 3-5 <br /> Address: '� ._.._ <br /> City, State,Zip ;`';c-t 1-1,v-y-\ C". ._--) 42'73 r 1 Fax: <br /> E-mail Address 1-)01-0 L., t':s r: 6^ .r2f,,,,,ra. /,elcrp-.,.- <br /> AUTHORIZED REPRESENTATIVE: <br /> ci <br /> Printed Name: t i t‘U' ar- ��` 6`t 'a£,- <br /> f <br /> Company Name Tt J ('i P er/L`V c (si rr' r Cg, (C<''.r''aa6)(/ `-' <br /> Signature:'`-1! ;:r _ , ;,. �� , 1€,..::-L., f Date: „,./79/: <br /> Address:_________"7:i1,7(.1 -• `ca, 1t r!,7 c� Phone: `X`3 F81-ti 2& <br /> City, State,Zip ...7-- - <br /> -.kk'''I . O'1. �t 73/7 Fax: ..,50',377/ -(-/04/(,) <br /> E-mail Address ../xi.-retellV reei (`''', x04 .;l-(7(:),"•-r r. <br /> DEQ License# GCB 4 J,5'6''&:- 5 <br /> Ci:w eRMSSSbI''CIC\S-O7 Aurn ID APPLY.DO(X Rev 3i IO.3 I <br /> fla E CEIVErn <br /> JAN 2 7 2022 - <br /> Bfll .rtjL. .� €:tree+Itis ° <br /> U LlFDlN�,�(pl d�`.6'EGIf�` ► ! <br /> dd- O-18 <br />