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d CSZDS 56.9 <br /> - <br /> MARION COUNTY PUBLIC WORKS <br /> : BUILDING INSPECTION DIVISION . RECENEn <br /> E„. 51..55 Silvert9A 10 NE <br /> :114W=et-ia Salem QR 97305 AUG 25 no <br /> (503)588,5147 Fax f503)588-7948 <br /> MARION COUNTY <br /> • hittpilivicOoulliarion.or.USIPWIBUildingInspectiora <br /> BLIP DING INSPECTION <br /> NOTICE AUTHORIZ1NQ REPRSENTATIVE <br /> I, ---75-0,g-A 5 vAo, D5 boir v‘ ,have authorized <br /> (ProPerty Owner/Print Name) <br /> _ - 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 treatmentpi-ogrAni <br /> services provided by the Department of Environmental Quality or County Agent on the property <br /> described b,elow.in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> 2.-3,""/ <br /> Property Situs or Stet Address <br /> And described in the records of MARION County as: <br /> Ac4e,e0 yq.ecif <br /> Legal Description ivinue: 4 3 tv2.1 0_0760 -cod. .e- Tax Lot#(s) R.31 2I c <br /> wrciza <br /> PROP-ERTY OWNER: <br /> Printed Name: cj--D.g (A,_. '45,0R.A, <br /> Signattre: Date: ,p9il7.y(7.....7,4 <br /> AddresS: eToieWitiu Sr: 5.4- Phoffe: 3/-4 76E3. <br /> City,State,Zip "4i.e/t4 04 73/7 <br /> Addressddres i1t'.41 Ocere-60.&-, <br /> AUTHORIZED REPRESENTATIVE: <br /> Company Na e <br /> Signature: Date: ,0104 446.\ <br /> : 503- 1 <br /> Address: PO Box 504 Phone 743-234' <br /> City, State, Zip Turner, OR 97392 Fax: 503-743-3638 <br /> E-mail Address office@bethelexr-coro <br /> DEQ License# 36198 CCB# 44551 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />