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6/1 yi6, , /API- <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> - -r 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, <br /> fo IA Q'ry c have authorized <br /> (Prope ' Owner/Print e) <br /> ki C r . 1 ( 4 GLr� C&J&h9(-- 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 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 /> l g 3 f6Q�e Ctr ,0 s <br /> V Property Situs or Street-Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: g o h are 5"S <br /> Signature: Date: q 2 — Z© 24 <br /> c <br /> Address: 7 7 {' Cde Or 5 Phone:,.5-e3,3- q.2g-,j 00.5 <br /> City, State, Zip Sq I et,.` 0 iz q '3 O? Fax: <br /> E-mail Address Ca vn e- S&• <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: d Tk <br /> Company e SC 4— 0011C- <br /> Signature: Date: <br /> Address: cc ri 0:2 Phone: S _q <br /> City, State, Zip k 3 O'R, o f-73 Fax: <br /> E-mail Address nftft tfiLat9.5 e vf, . C- 11n <br /> DEQ License# CCB # (p q /q <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />