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sill444q,'I+ MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> • <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, <br /> ei/vaiv // kiltia/k/ ,have authorized <br /> SP/ Sz,Li l (/lf�PropertyOwner/P�rintC Namel(I � /C C. /1a&rto gas 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 /> 34'oao / _(_j/-&.•ceo( (71. 4( 973 C/Z <br /> Property Situs or Street Address 1� <br /> And described in the records of MARION County as: <br /> Legal Description T9R yr sEc 30-L //OQO Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: ///t,/d/ <br /> Signature: Date: <br /> Address: L__sy, laz./iqa&d a/ Phone:3"03 99/ /6 9A9' <br /> City, State,Zip kj /0- Q 3 / Fax: <br /> E-mail Address 3,-'L,Qui/der5. g-/9 9m4�Y eat Z <br /> [ <br /> eh2ura,) 8'(� 0o/ God <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: A 'h e/ ha..1..tra__, <br /> Company Name: $PL /520,L/'27 e4A J / Z C <br /> Signature: NC.l� Date: L/(-6-4 __V-.3,7 -2-7,57C <br /> 17/2o / <br /> Address: 3'-/Oc9. GI A 001 aZte J Phone: ' <br /> City, State,Zip (�� Q2 qT 3/& Fax: ./V/4 • <br /> E-mail Address ,_5/ Bibi/if�S d k/9 <br /> DEQ License# CCB# /7s-est/ <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />