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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> ue <br /> 555 Court St. NE Room 2260/PO Box 14500 <br /> Salem OR 97309-5036 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://publicworks.co.marion.or.us/building/ <br /> NOTICE AUTHORIZING REPRESENTATNE <br /> I, 4--t-tPuvity -e!./ fe , have authorized <br /> (Property Owffer/Print Name) <br /> 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. I agree that any costs not satisfied <br /> by the Authorized Representative are my responsibility. <br /> PROPERTY IDENTIFICATION: <br /> G7L17 1 eSSa L►A E;IVer,1-00 OR CI? <br /> Property Situs 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: 1 e,1/4(u.i►-.l-e She )✓ 4\-e-kf-, <br /> Signature: Date: i /2 / L0 <br /> f I Phone: a 3 b 2z <br /> Address: 114 65 S �b.�q q RBI N� S: �,-J�n � S ��( <br /> City, State, Zip q-73? 1 Fax: <br /> E-mail Address Al t.x S n e 9; revt H-0-✓h 4.I:C o of <br /> AUTHORIZED We <br /> Printed Name: Ike rbt V'-{' ( . L)t 15 n IR J <br /> Company Name: Lon t A yl v COirn k- SRA) .1-11C- - <br /> Signature: lAvvirtraC Ia) I,C1'\ Date: <br /> Address: t 1-455 C.as n„ PIG& .t/F Phone: 003-?AI- 5-4 <br /> City, State, Zip Si\J(J e Q . t al`4--Scal Fax: 5 0-5- S-I3-55 Cog- <br /> ' il. <br /> E-mail Address i p�1,t InC S `' Cp(M <br /> DEQ License# ��oo� V CCB # /f3-O023 <br /> S-07 Rev 03/05 <br />