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• aq— t5bUFD9DIA <br /> • <br /> • ,f,� ��',;, i MARION COUNTY P"tJBLIC WORKS <br /> DIMMING INSPECTION DIVISION RECEIVE® <br /> 5155 Stl(Yy�vert son Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 AUG 16 2024 <br /> ht4)://www.eo.marion.or.us/PW/Buildi n gInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> %4G I, have authorized <br /> ,//�� (Praper 'Owner/Print Name) <br /> & i e;loce sot, to act as my agent in performing the <br /> . ( thorized 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 /> • <br /> PROPERTY IDENTIFICATION: <br /> 23 G 17'• 8,4 4,a. w 4,J, 5-, <br /> • Property Slius or Street Address • • <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: �Lt,piiC O i '/ • <br /> Signature: *2 �� � Date: l ` - -24)2-,/ <br /> Address: I 3 G 4/ 5 Vc cT £d, .S. Phone: ,g "3 - a2S"7 <br /> City,State,Zip Jg.PPe.,-rah d# el71.s Fax: <br /> E-mail Address in n m s Ra..rm mit it 60 in <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: eopt Y X!L4 efld • <br /> Company Name: SiJi ,d Red< lrt4C. ¢' &t viti I-L(?-� , <br /> D <br /> Signature: � � � <br /> Date: <br /> Address: Jig rib Evoke- 67d .I( Phone: jp .6-7D <br /> City,State,Zip inionfit D iLiA , OR 9 / Fax: . <br /> E-mail Address 34/ardakc s4 dinar;/. coot <br /> DEQ License# 3 9/77 CCB# r,2 4 9,24 • <br /> OffORMSISEPTICI307 ATM TO APPLzDOCX Rev 3/r0,3/1 s <br />