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ke5b <br /> �ti MARION COUNTY PUBLIC WORKS a� ��/ � <br /> 1j��"''� BUILDING INSPECTION DIVISION RECE� V ED <br /> �l` . 5155 Silverton Rd NE <br /> am—"' ---, .•' Salem OR 97305 JUL 112024 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Ra1Th A. -..\acksc t E4.i-411 alei-siine_ --,Seson ,have authorized <br /> (Property Owner/Print Name) <br /> r on Sewer& Drain LLC) <br /> Hansen ( O Oregon 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 07l. <br /> PROPERTY IDENTIFICATION: <br /> 1510 Gosnnere c-.,n Sk o,\I +0.,‘, OR q--7 3R3 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) Li `4(oO6 <br /> 5 34 bob <br /> PROPERTY OWNER: 5 34 C9t1 <br /> Printed Name: lo_r_1_, A . c-cksort + �.aZ e. Ac,_r_. -SoyISignature: C Date: k1 `� Z. <br /> Address: 1610 Co S S ovveve L.JA Phone: 5 Q 3 -(130 --t]ZS <br /> City, State,Zip c�-k- 'n, O `11 3 S 3 Fax: <br /> E-mail Address re-\eliA ' c�ckSon kiOt Wto;s` . Cow.l J <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Orreeg n Se er& Dra. LLC <br /> Signature: / Date: '7-3-a'Z I <br /> Address: PO ox 1 82 Phone: 503-874-9414 <br /> City, State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 I <br /> I <br /> G:\FORMS,SEPTIC'S-07 Auth to Apply.doc <br /> 1 <br /> MCS-07 Rev 03/10 1 <br /> SEPTIC 4 j <br /> I <br /> 1 <br /> f <br />