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DocuSign Envelope ID:65B3FBCC-6148-4CA9-BDDD-99E3A49272AC '_DD4 ) 1 Li-_fl, <br /> �� MARION COUNTY PUBLIC WORKS <br /> '�iI ii„'"ice BUILDING INSPECTION DIVISION <br /> %1��� 5155 Silverton Rd NE <br /> - " Salem OR 97305 <br /> log (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, /whew o lA-. , ,have authorized <br /> (Property Owner I Print Name) <br /> �/ ! /01-.6vy% to act as my agent in performing the <br /> Au�ddRepresentative I Print Name) <br /> P <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 /> qq3 f MIL.-Alig LW- S , n 5d 17 L . 97- 32_5 <br /> Property Situs or Street Address • <br /> P <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed. : 0:-.- igned /124041 0`ki-6/j <br /> J 0 I 6/12/2019 1 12:24 PM PDT <br /> Signatur;: Date: <br /> • <br /> -0A351D118FA3461... <br /> Address: 093/ l -eA d/E La• se. Phone(563) 939- 0 )3 <br /> City, State,Zip A vvl5'l)j /a2 f ! - ,9g3Z-6 Fax: <br /> E-mail Address a.,5C /6949e,0 C 4,11., /C v t... <br /> d <br /> AUTHORIZED REPRESENTATIVE: , <br /> 4Printed Name: I(/ I-t-M-ni -' <br /> Company Name: , JJ ,14A. ui , • ' ," ` , . <br /> Signature: 4/ . fr„,...-._2;....------, Date: /2.- /9 <br /> Address: pc, cl o g_ 3 2 53 Phone: 5n2j °t` 3(a L9-9 <br /> City, State,Zip Sif tekvu C94. q?32-5 Fax: <br /> E-mail Address Cha kit <br /> it, eO/,)f, L,,q/'i5t,,•,j4n44 19641/F5,, <br /> DEQ License# (/ CCB# igg60/ <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />