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MARION COUNTY PUBLIC WORKS �5_ dn71 <br /> EIT. <br /> ,ti1 ���14" BUILDING INSPECTION DIVISION ® I v <br /> 5155 Silverton Rd NE <br /> JUL 07 2023m„i Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> http://www.co.marion.or.us/PWBuildinglnspection BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, !��-✓1� �S ,have authorized <br /> //�� �M (Property Owner/PriAName) <br /> l��_ Y Elk/1 l� t. t/„�r 4- sa h 3 Lows--1-rtka-tbk 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 /> 3Z3l ice = tee-1 c st ' - t o- 9 7:30 z <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: y� <br /> Legal Description )-CC vi,tn.:# .56o g 2 Tax Lot#(s) 0 id I B <br /> PROPERTY OWNER: <br /> Printed Name: Pc524/1j c'4(- t cs <br /> Signature: De.4 Date: 7" z 3 <br /> Address: 32 3( 4- f 31,ei- 5 er' Phone:;d3 570 'TM- <br /> City, State, Zip 5 --1-P%Y4- 1 q 7 3 dZ Fax: <br /> E-mail Address c ,l/e c R c Q5 . co m <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: (fit ii f k iA t.e c4, <br /> Company Name: e a I So tt S. v-EA_C ° (, <br /> 23 <br /> Signature: Date: <br /> Address: 7 3/ /W g S, Phone: 503 Z 7-q 3/ zit( <br /> City, State,Zip 5.2-lnn E)R 1 '3-3O( Fax: <br /> E-mail Address U Q.vl� `2 3 J t 4- oil. ofAi <br /> DEQ License# CCB# 1(37(9 <br /> G:IFORMS\SEPTICS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />