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) .--T5b D.35-7 <br /> '�II�����,, MARION COUNTY PUBLIC WORKS <br /> 'il'" BUILDING INSPECTION DIVISION <br /> 111u 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PWIBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> �jCr ,have authorized <br /> v (Property Owner/Print Name) <br /> • �Czr�►'1 va.i to act as my agent in performing the <br /> (Augorized 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 /> (�3 ZJ ids Otityls l,- e iv S 1/ 4 D2 9 -73oi <br /> Property Sims or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: y k 4G5 <br /> Signature: J< Date: 3 -3-;-3 <br /> Address: 193-14 , atA•eja- 014Ct. Al4 e_ ,6. Phone: 503 9 J© `,Z 1J O <br /> City, State, Zip_ „cc, fir o* 9 7305' Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: I-0-v r y <br /> Company Name• �/ <br /> Signature: c-ieic: <br /> ��S �- Phone:Date: 3-3- <br /> �L <br /> Address: / 71 �73 -3 9� �/ <br /> City, State, Zip J-(,�y Oi? 5 wo <br /> / ( Fax: <br /> E-mail Address 15Sm;'k la279 y� i C--04th <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />