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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/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, <br /> g55 M 1 I iv Db 11 Vi(�t— L . l ,have authorized <br /> J/ (Prop rty Owner/Print Name) <br /> go6 /425x0 M p Som S�`V 5 LLC-, to act as my agent in performing the <br /> (Authoriz d 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 /> 35925 s71-sr' L o•�s, VC' �3 hoc ) <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description,//s , -/Kh b s,b�6 3 J L Tax Lot#(s)0811E32.e fir,3/o0 <br /> PROPERTY OWNER: <br /> Printed Name: Awe,— L • Y +fnn+<<l°�0 <br /> Signature: ^G� " �� �i I t.te: 2./I7/ZOZ1 <br /> Address: 1 55 V ?S+�VYtVVIC'.V' Phone: 5C - 1 Zfl <br /> City, State,Zip 77 iva / Q JZ. q-]223 I Fax: 4/A <br /> E-mail Address all ( Ips' 1/161411.-01,0 O l . l.6YY1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: 5,z,2 S -rv,c 5 LLC <br /> Signature: -: Date: 6221/gJ�cvzf <br /> Address: Po 5e,Oc S/ Phone:5o?85-4 2 <br /> City, State,Zip 47,/ Ge y/ or. 9-7 3 6 c) Fax: <br /> E-mail Address /`��hm - eb o'yi�r.pl Cc2m <br /> DEQ License# 3 9Z L CCB# /if/p&" <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc / <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />