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MARION COUNTY PUBLIC WORKS pZ LcPt L 1 <br /> =i. BUILDING INSPECTION DIVISION s~,ECEIVE <br /> 5155 Silverton Rd NE <br /> • Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 AUG 15 2024 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, DOrr15 M Bzr'tvz z L.i Y i n 7 i[S have authorized <br /> (Property Owner/PrinnYName) <br /> MarK S ...& ,h LL rnae i er 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 /> /2Q9g /JJ .Si y&i 7iG1 6E, Minns I/ oe 9z.3.v5 <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) f/210/) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: To(15 /v1 3irb3Z L-&vcn3 TruS+ sand MSCili rnadle;1 i5 <br /> Signatur 1/11 gJ /1 / �/1//1aM4AU} Date: g-j_q- [2� <br /> Address: /67Q Lehr,-/ 5,E Phone:5j3-9 /55,q <br /> City, State,Zips+2 y r 9/ 97zga Fax: <br /> E-mail Address ne- C.GUSorP_�`l on,(•On') <br /> AUTHORIZED REPRESENTATIVE: . <br /> Printed Name: Mari< ,9 �Schccn�Q�he�r <br /> Company Name: Ai/% <br /> Signature: �� Date: 8/3 o20.24 <br /> Address: 1470 J-$lnn I Dr 5t Phone:,59,3-qc=1,9-40,36) <br /> City, State,Zip.Stogyy-f-On, OR 9 73g.3 Fax: <br /> E-mail Address ,yor/ ( C!w1S4iejo 7, my) <br /> DEQ License# CCB# MA <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />