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--110111 <br /> MARION COUNTY PUBLIC WORKS - r! 6t41-1 <br /> BUILDING INSPECTION DIVISION <br /> -xs 5155 Silverton Rd NE <br /> Salem OR 97305 APR 17 2024 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/BnildingInspeetion <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1 A S: — 13-- f a_3 ,have authorized <br /> (Property Owner/Print Name) • <br /> /g IrYy %vzwear, Ci et;1 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 071. <br /> PROPERTY IDENTIFICATION: <br /> Snfi k /* 02 9. 73q6 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description-6Lve k'• Fte. Ln'1 I Tax Lot#(s)(--)9 r7 d r1 o f g c-0 <br /> R. 2. V4c2- 5 IT <br /> PROPERTY OWNER: <br /> Printed Name: ./ Ytjlt�?i i .fir tbeil <br /> ` I <br /> Signature: 7(\l/L-L-e----,---/ Date: '-3-. Lit <br /> Address: V.A., '6-Y., 4 Phone:'CGS--353--07: <br /> City,State,Zip M\\\ (` ‘ y 2 91'3(4,0 Fax: <br /> E-mail Address C v'(3O\S;)54-,v, ,16VOD . e i^il <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /y'K /L e-u kor1 <br /> Company Name: Cie S/OJ? L L C <br /> Signature: l�� fV e�//J` Date: <br /> Address: _`i q.?D Jr•1;pe r- S r- Phone: 563-- 9.3 — <br /> City,State,Zip S'o_te ?/Z `e 7 S Fax: <br /> E-mail Address L./ S/ vZ 6-2 Ve-A - <br /> DEQ License# I GI 0 CCB# r,2 i-7 S/L/ <br /> G:FORMS\SEPTIC'S-07 Auth to Appiy.doc <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br /> • <br />