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' ,,,; MARION COUNTY PUBLIC WORKS <br /> �'il '',",`' BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co marion.or ns/P'W/BuildjngInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, ?IL , ` 4r-)04' S , L L _ ,have authorized <br /> `(Property Owne=/Print Name) <br /> f y 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 Qnility or County Agent on the property <br /> described below in accordance with OAR chapter 340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> 2( 4 - _ c -73 '2Z <br /> 1e 4;n 1 .z G S 1 27S t' S Property Sous or Street Address <br /> r3ae.1 L>t�4ca�nf- Get <br /> And described in the records of MARION County as: .11 f/ <br /> Legal Description Z o f 56 # - nix Lot#(s)R 2�.3 512G '-- <br /> L o -t- N a'- a 75 Ba tt1— 2; g22-E( <br /> PROPERTY OWNER: 74 4 - <br /> Printed Name: . r^e $ .I. 2 L C - <br /> Signa r _ - — Date: 2 4'— Z.2 _- <br /> Address: 3 4.41-d' #4 zro .�. _..ttE Phone: fJ 3- 4(7(-.3.f i/e" <br /> City, State,Zip 7- -- '? ? 3 0`( Fax: <br /> E-mail Address ':t . rn4, f 4 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name:_ t ye,lt/ <br /> //JJ pe, '1 714 <br /> Company Name: �GfJP�! (A <br /> Signature: _ . _.... . . <br /> Date: ZV 2Z <br /> Address: X c Sept' 7//fin /��/7�f:®✓.. Phone: <br /> City,State,Zip Cc1 Fax: <br /> E-mail Address 9 fe, l <br /> DEQ License# 3$3q CCB# i563.c7V <br /> GAFORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />