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la ."00 ?4((( 4)16if r <br /> rid ',q, <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> ,___\, .._--;'`�%;�--_—::: 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> mil <br /> (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PWBnildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, 7110"TA s 91— R41-2gg o. So 1,,0 ,have authorized <br /> (Property Owner/Print Naine) • <br /> 3,151.,\_ e4, _Os"cie..,t x,r 4--0-,.a,, L ex._ 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 /> 703 / s'" Sr, Sco,Tr- MiLLs f Olt 17 ? 7s <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description O(— /,F — /,‘ C.d Tax Lot#(s) O/Oo <br /> PROPERTY OWNER: <br /> • <br /> Printed Name: 7?/0 of,L s Z S 0 t/p4- <br /> Signature: % Sp-, ..-- Date: 7-2.Q-2y2,o <br /> Address: /2.f Y ,3 2 "'d ff✓e .v Al Phone: So;- 3 6 3 - 7 00/ <br /> City, State,Zip 5,q.L wt , 0 2 9 7 30 Y Fax: <br /> E-mail Address Th S o volt. O. 4-o L, 0 0„1 • <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: i Cr S t id <br /> Company Name: v— <br /> Signature: �� ___ ----- Date: IC) -7&-7 O <br /> Address: -1 � - (mil Phone: Sea —g".7L/gK/y <br /> City, State,Zip S1"1 t w---- rYY� cr23$-/ Fax: <br /> E-mail Address u csS O i '-C <br /> CO- <br /> DEQ License# (o CCB# - _40 / 6 S 3 <br /> G:\FORMS1SEp77ClS-07 Aath to Apply.doc <br /> MCS-07 Rev 03/10 . <br /> SEPTIC 4 <br />