Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE ( V <br /> ' ED <br /> • Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspectitInll APR 0 7 2021 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> SCI, i , ' / / C � .9V‘ <br /> , have authorized <br /> (Property Owner I Print Name) <br /> /G v !R 014U i 5 to act as my agent in performing the <br /> (Authorized Representative I 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 /> 3it- 5 -6i4,44,0., b 2 a., , ' Lyon c5V 9735? <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: n ,gyp <br /> 4.Printed Name:"i f <br /> Date: j14/ 03 J <br /> Address: ,0 0 / Phone:3-e- <br /> City, State,Zip Z r0/2-),5 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: (/V r lq z2 a 1/15 <br />• Company Name: <br /> Signature: Date: a 7 - <br /> Address: 02 J X e2..5 5 / �z,ry Yy14 � Phone: q7/ -o?' % 52a 7 <br /> City, State,Zip L / i�.i S & g ,e T 7 3 5 Fax: <br /> E-mail Address j iJ, L) ✓v ,47 y/ee. /74 v <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />