Laserfiche WebLink
• • <br /> �I ``•q, i ` MARION COUNTY PUBLIC WORKS s 74'05-F02 r41)7.14 <br /> ''ue BUILDING INSPECTION DIVISION r°y <br /> `e4 r U <br /> 5155 Silverton Rd NE <br /> 'ECt11VIETI <br /> itjj <br /> Salem OR 97305 <br /> - •= f_74 4" (503)588-5147 Fax(503)588-7948 ,J1J�. 01 ZDZ2 <br /> ; http://w�nv.co.marion.onus/PW/Buildinglnspection <br /> fv1ARION COUNTY <br /> BUILDIN <br /> G INS <br /> p <br /> ECTlON <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Darren and Sarah Hendren <br /> I, ,have authorized <br /> (Property Owner/Print Name) <br /> Dorson Jackson 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 /> 5525 Serenity Dr a SE Sena OR 973•37 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description taaglevoted Wires:NO 2 F.et L Block 4 Tax Lot#(s) oa3Wa3D S004.00 <br /> PROPERMOWNER: <br /> Printed N e: wax Hendren <br /> _--� Signature: <br /> 4�i Date: 5-13-2022 <br /> Address: yDeiceSE:+alecn OR97307 Phone: <br /> City,State,Zip Fax: <br /> E-mail Address hertdrence serucfimEoYaIiocn-com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 112r7All.Ia4:Katr` <br /> Company Name: .Ea+k0n Cemua. si Cans, ct m,Inc <br /> Signature: A1ik Date: 5-13-2022 <br /> Address: PO BoX3412 Phone: 503 559 oe7t <br /> City,State,Zip Salem,OR 9 3oz Fax: <br /> E-mail Address dorsaujackson@g atlie tn: <br /> DEQ License# '-Jane CCB# nn°476 <br /> G:IFORMSISEPTICN.S-07 Auth to Apply.doc <br /> MCS•07 Rev 03/10 <br /> SEPTIC • 4 <br />