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• <br /> MARION COUNTY PUBLIC WORKS <br /> 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.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, ( / /947 / /1 G 11/\/ ,have authorized <br /> (Property Owner/Print Name <br /> SPS S/LI/lira; M/C IO e/ / Cfl�rto ac 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 Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> 3e/o070 9 -34/Z0 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 79R V S Z&2 TL // 'O Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: /M/4 /(� IAO <br /> Signature: Date: <br /> Address: L y ) iseereeeid az.eg Phone:30.3 99/ /6 9,P' <br /> City, State, Zip. L• Z2X Q 23CV Fax: <br /> E-mail Address pz..,Bal/ders ff/9 g 0191a i'/(10 CIL <br /> eha tt,ran &''J Go% 60 n-)1"/ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /)/(h0 e/ 8 C=J/�_L�L YO./) <br /> Company Name: SPL /g/a/aG <br /> Signature: C.l� Date: ,-/b/2Ua- % <br /> Address: 3L/OcaO ()ase,A C (7Z,te Phone: (6?,23)93 7570 <br /> City, State,Zip &2,4, <2 97 3/(p Fax: /f� . <br /> E-mail Address S,O/ k/9 Ggm a.,;/ (j/Y) <br /> DEQ License# CCB# /7 ? S 7 <br /> G:\FORMS\SEPTIC\S-07 Auth to AppIy.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />