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r'ECEIVE <br /> t I. 4i `4 IVIALOi' UJUN'll PUBLIC. C11JUL 2024` 01 <br /> i ' '- p Atu BUILDING INSPECTION DIVISION <br /> -,".. ' ,' 5155 Silverton Rd NE <br /> --�- Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> . http://www.co.marion.or.us/PW/l3u.ildingInspection,. <br /> NOTICE A.U`.:itORIZTh G REPRESENTATIVE TI <br /> I, 1)Ch viz, Ecc ,have authoriz <br /> (PropertyPrint.�-,. Owner/ -Name) <br /> /-"Cr: : ,c to act as my agent in performn. <br /> Authorized Re resentative/Print Nanie) <br /> activities necessary to obtain site evaluations,permits,and other of site wastewater treatment p <br /> services provided by the Department of Environmental Quality or.County Agent on the proper <br /> described below in accordance with OAR chapter 340,division 071. . <br /> PROPERTY IDENTIFICATION: <br /> 66 GI _5 ky t,i.i.e.__. ici -5. Sax.... r Ot&r i7?GAL <br /> Property Sittig or Street Addr ss <br /> P <br /> And described in the records of MARION County as <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER:OWNER <br /> i <br /> () S <br /> Printed Name c 6 rtf-N <br /> Signature /Z:s/zw <br /> ` Date <br /> . <br /> Address 6 S c7 f, s Phone <br /> City, State,Zip SaL -i n4 17 34.O Fax <br /> E-mail:Address: / <br /> AUTHORIZED REPRESENTATIVE <br /> Printed Name. <br /> Company Name: <br /> • ,,Signature; Date:. <br /> —*Z-,2--______ <br /> Address: P. ). t l go l Phone: SO <br /> ai <br /> - <br /> City, State;Zip ,i 3? S. Fax: <br /> E-mail Address C r Y 11, (• <br /> DEQ License# 3'1 fit-,i <br /> CCB # bF ---? <br />