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1VIARION COUNTY PUBLIC WORKS BUILDING INSPECTION DIVISION 1 1 -C�r 1 <br /> Ue <br /> 5155 Silverton Rd NE D LE �� -\/J <br /> E rry, <br /> Salem OR 97305 C' �- <br /> (503)588-5147 Fax(503)588-7948 MAR 3 1 2021 1.-- <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NIA F €ON COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, !C g C ,have authorized <br /> .(Property Owner/Print Name) <br /> pooh l 001 to act as my agent in performing the <br /> (Authorized Rep esentative/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 /> /2 G: 52732/3/A) 61,71 <br /> 6-�� �(-fin) Q73 fe, <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) rR3E.21 cCc-)3ii c 7 <br /> PROPERTY OWNER: �/ <br /> Printed Name: CoL l;' (P,15Th/e) #ore d� !�1''7ifT eia/12edy <br /> Signature: _ Date: 3' --S - .l <br /> Address: M". gPX /p 5 37- Phone: 6'`53)2-77 -3 <br /> City, State,Zip f id/ 4 j O/C', 9 7 C6 Fax: <br /> E-mail Address ItiliAJ f d2 I tio e <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: F-70✓ p;c7f7 <br /> Company Name: ys '_<v4 sue!vies <br /> Signature: ��/� Date: 034_5-1„. 49,x1 <br /> Address: Po i3,0y G./ Phone:521'3 <br /> City, State, Zip Milt y�, Q�' "j-7_3 e5 Fax: <br /> E-mail Address /`e,4"%� ,/ ects,1 <br /> DEQ License# 7 9.,, CCB# <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />