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a it 67)59'5) <br /> RECEIVED <br /> 11012 <br /> JUL 3 0 2024 <br /> iviAtuuni cUtiNTY.eutchic wooAs <br /> 74s7 BUILDING INSPECTION DIVISION <br /> , 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 FaX(503)538-7948 <br /> • I http://www.co-marion-or.us/PW/Buildingluspectiort <br /> NOTICE AUTHORIZMIG REPRESENTATIVE <br /> ,have authatiz <br /> (Property Owner I Print Name) <br /> to act as my agent inperformii <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits,and other onsite 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 /> Do <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot ii(s) <br /> PROPERTY OWNER: <br /> Printed Name: <br /> Sitature: Date- -9A <br /> Address: f.O . ge3le "74 Phone: <br /> City, State Zip cz 014.- -7 3/::$, Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: Er <br /> Signature: Date- - L/ <br /> Address: /("). (2unie tev/ Phone: g Otz <br /> City,State,Zip lieti"SatC4 6 4 7 32S— Fax: <br /> E-mail Address ,cc) <br /> DEQ License# 7)1?).6, CCB# 7 <br />