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e Z'ei - °°61-ic4--/ieelir <br /> •..04•1/4.,„ <br /> 41104... <br /> .........., <br /> ....„.-....,,--.,,,,-..". <br /> -.4,04-....... <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION IMARIONLDI <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 14AdEf 2 4 2020 <br /> (503)588-5147 Fax(503)5884948 <br /> http://wWW.co.marlOn.or.us/PW/BuildiimInspectio:U <br /> 1.111 NGINSPECTION COUNTY <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, A (J\CJ( ,have authorized <br /> Dv,... Property Owner/pint Natneln <br /> 3 ..35 /10 I de ../.44/1711 to act as my agent in performing the <br /> •(Authorized Represen,tive/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 IDENTIPICATION: <br /> k \C5---VC OOL\c. ' ,Nc- Se ci-t -Th Of-- •0\--1 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal.Description Tax Lot#(s) <br /> PROPERTY OWNER:. <br /> r., . <br /> k Printed Narne: k,.:.-\kr`\6`-k,A CX(3,..Ai \C_,, <br /> ikSignature 0....,---- ..\,..„ - /0-fl_dk....— Date: g I 2-11 7--(3 <br /> i\-- Address: c . Phone: 50:511-6\- V=\%k 4 <br /> '1..City, State,Zip Sa-k-er YThr\ C.5`9,- Ck-Vb(13(,..x) Fax: It <br /> tk7 E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> PrintedName: , 1 t 55 . :51-44/4/1 <br /> •Company Name: 4 . i'pi prq;II "--/ <br /> Signature: --"----: Date: 7/01/1 f <br /> Addres.:---300 ires4 ykii y- A56 Phone:F03-... 73.2.,2:Vo./ <br /> City,State,Zip m 5 40 le 1 O! 7 7317 Fax: 5-63 - CP5,- fl / <br /> 77 <br /> E-mail Address 3r- a c-i-tosi drii-di. 3 Ai q;./. .05irrl <br /> DEQ License# 3‘32.3 CCB# 50/7/ <br /> GAFORMS`,SEPTICS-07 Auth to Apply doc <br /> MOS-07 Rev 03110 <br /> SEPTIC .4 <br /> — — — . <br />