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���� `IARION COUNTY PUBLIC WORKS <br /> "'ii `"" BUILDING INSPECTION DIVISION <br /> � � �� 5155 Silverton Rd NE <br /> �` M = Salem OR 97305 <br /> Milli (503) 588-5147 Fax(503)588-7 48 <br /> http:/(www.eo.marion.or.us/PW/Bnildin Inspection <br /> NOTI E AUTHORIZING REPRESENTATIVE <br /> I, Jt .&e5 .�.ri-;► th.L; , have authorized <br /> (Propert3i Owner/Print Name) <br /> 4. ei r� Ito.-4 = ,r-At socr, .to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits, and other onste wastewater treatment program <br /> services provided by the Department of Environmental Quality or County Agent on the property <br /> described below in accordance ith OAR chapter 340,division.071. <br /> PROPERTY.IDENTIFICATION: <br /> 5sgt,f Karla Cyr 4 <br /> Property Situs or Street Address <br /> And described in the records.of MARION County as: <br /> Legal Description [3 e, , 1'S DA Tax of#(s) 1$3 t i.;i 3 b A ,*i o a <br /> PROPERTY OWNER: <br /> , <br /> Printed Name: L- ci,,.,.; k,. <br /> Signature: ,,,,,4 Date: 73 etv-5 3 I <br /> Address: 5` ta •,. r 4- .E Phone: <br /> City, State,Zip Sale-106% 4 01-7 3 17 ax: <br /> E-mail Address •Moir A-;cL4c ..% e e,„c s4 ,tt.e. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name L:5 e, -14 - ,1...e8.., <br /> Company Name: p1Stt vt. �_c ,,,G. Dei4- cr e. ` N.fi. Sa CA`"s' <br /> Signature: Date_ g-50-r .( <br /> Address: 33.11e : s k ;C �c►.a lE'hone: 591 t-2i'-1-c(3`?i/ <br /> City, State,Zip .1,6,,,,..., toe- qZ3 -5- Fax: <br /> Aifi, <br /> E-mail Address 16 oe@ �� � 5-ear <br /> DEQLicense# 379c$ I CCB# att)(30 <br /> G:\FORMSiSEPTIC\S-07 Auth,to Apply.doe <br /> MCS-07 Rev 03./10 <br /> SEPTIC 4 <br />