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MARiON COUNTY PUBLIC WORKS vZ�-6b5lik 51A <br /> '"'"' _ BUILDING INSPECTION DIVISION <br /> slss silverton Rd NE , <br /> 4 �• Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 11 J U L 16 2024 <br /> j http://www.co.marion.or.us/PW/Bnildinglnspection <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> a_0,3 \ /ca5o,3 ,have authorized <br /> (Prope Owner/Print Name) <br /> l P AIL moy to act as my agent in performing the <br /> (Authorized Represents ive/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 /> t2 t3f ie$c, ikre., i-# I qutf Q- '17i 3 7 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: S eQ ki <br /> Signature: ��J'�-�-�` Date: Iti ,2u <br /> Address: +1-1-41\ Cy-1 0 a' - 99 Phone: WS-7s-6 <br /> City,State,Zip S"i • n L bfe-- Fax: S 6.1 (33 `/O ZS <br /> E-mail Address ^, e . 7')1-5bP "<( rent)). iL : C'5W) <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: {44 Fret- 1 <br /> Company Na : IOtGCOd4 /67y1£$ &LC, <br /> Signature: Date: 7//O/Z)4?9 <br /> Address: !'I5I Pta Phone: 563-S.579-9e466 <br /> City, State,Zip Pkoz. � ?pg. 7/37 Fax: <br /> E-mail Address rle: €a, dts titpk y 6'gt 5Al. -t <br /> DEQ License# CCF# /62 6-G 3 <br /> G:IFORMSISEPTICLS-07 Auth to Appty_dor. <br /> MCS-07 Rev 03f10 <br /> SEPTIC 4 <br />