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MARION COUNTY PUBLIC WORKS C L C©�1]VE n <br /> '„, BUILDING INSPECTION DIVISION Ti <br /> viARioN <br /> 5155 Silverton Rd NE DEC 2020 <br /> Salem OR 97305 COUNTY <br /> NG <br /> (503) 588-5147 Fax(503) 588-7948 ���➢ INSPECTION 2 4 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, ,have authorized <br /> (Property Owner/Print Name) <br /> I-red (/ f �� Cttev) to act 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 /> 1004,3 MOO/It LLi a vT , R iSS <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) C -1,3 I.L i A 6 000100 <br /> PROPERTY OWNER: <br /> Printed Name: /-0)6 ER p fLA?ZEg <br /> Signature: t L�, ?�.s Date: j7! /2 312.0 Za <br /> Address: PO ilk Phone: L)3 6&/ w 64 7 <br /> City, State, Zip \30LEY-1 r by 9 7304 Fax: <br /> E-mail Address b " rex 6.Dvs <br /> m et ( L L,0;14 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /v-c�,� Cr Fc, lc c) vfrt <br /> Company Name: S L c- t l O,'v,c-5 L L , <br /> Signature: ' ;//� Date: j)e_c . 1 / 1(� 2..0 <br /> Address: 72,c("' / 13 o o k kw Itt__ (V E , Phone: CO3 - 43 7 1 3'(D00 <br /> City, State, Zip s e_�-t C-% Yc 9.1 3 O`; Fax: <br /> E-mail Addresso ��� �;, C ,, <br /> DEQ License CCB# C 3' <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />