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tiMARION COUNTY PUBLIC WORKS <br /> 11I��"'� BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE �_a <br /> Salem OR 97305 ® C E 1 V E <br /> 4htt (503) 588-5147 Fax (503)588-7948 <br /> JUL <br /> - 2 <br /> ://www.co.marion.orus/PWBuildingIns ection <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> \& v ,have authorized <br /> (Pr erty Owner/Print Name) <br /> Sc_o .c lam- to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> P <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 /> 1 ZZ33 5tauclecl Pku-e-e, ioccv. 4' 1 VS Arco 114G) <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description A C IZc 8.tokik1 Tax Lot#(s) )1-to 1 <br /> PROPERTY OWNER: <br /> � <br /> Printed Name: PG'rcv- 14e,vt <br /> Signature: Date: 71 Z y /7 <br /> Address: Z 35 z+rw ( , cae Phone: J o3 31 Co 8ER 8 <br /> City, State,Zip 'SZ vS0."- 5.7._ Fax: <br /> E-mail Address ., 1G 2 Cri:r ,.nc o vvyA i <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: �Zt Cy - <br /> Company Name: <br /> Signature: : ac <br /> Date: 7��7/Z _Address: 1 it1/4.)Z W Phone: 5r-23 .. `Ict 4 ctU <br /> S <br /> City, State,Zip S I '17 3oy Fax: <br /> E-mail Address ca.G 41,5 2 323 e ,ccw-- <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br /> II <br />