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�� MARION COUNTY PUBLIC WORKS <br /> 111 ,,��il„qpe <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> • <br /> Salem OR 97305 • <br /> Mill <br /> (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, -Doris M Bartoz z L i v i r ' -Trust have authorized <br /> (Property Owner/Prin Name) <br /> MarK S Sc.h tkma eher- 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 /> /62/4 i, 451-a y r) &L Sk, /)/ rnsvil/P, (ale 92/?5 <br /> Property Situs or Street Address <br /> • <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) /SOD <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: T <br /> Printed Name: ods /v1 PxCr4J5 Livifl��nc6+ i ftne-i- 11114,6 <br /> Signatur >r) 01_/11///9)!,,e1jeUj Date: .-/ --.4z) 2,1 <br /> Address: /670 L6j1/14l 73)-- E Phone: l3-Cf,/ G <br /> City, State,Zips y-tol 9°7 1 Fax: <br /> E-mail Address jne- C,1tt )re /)fl corn <br /> AUTHORIZED REPRESENTATIVE: . �`l <br /> Printed Name: Mari Sehecmacher- <br /> Company Name: A///l <br /> Signature: Date: -/3 O 241 <br /> Address: 4I& O J.s1and /7r C E Phone:59,5-CiA2-340,30 <br /> City, State,Zipay-6n OR 7,3k. Fax: <br /> E-mail Address mark CILISOrejOn, air) <br /> DEQ License# /1///- CCB# ✓M <br /> G:\FORMS\SEPTICIS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />