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\ b <br /> MARION COUNTY PUBLIC WORKS 15C _EiVE <br /> BUILDING INSPECTION DIVISION fl <br /> 5155 Silventen Rd NE MAR 1 1 2021 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> INSPECTION <br /> ° — http://www.ee.marion.or.ns/PWiBuildinglnspecion BUILDING <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> V4Pli irt— 14 it/ rit <br /> , ave authorized <br /> rp (Property Owner-07 /Arrint Name)yn:5eits47 etitlif kiectiql to act as my agent in performing the <br /> (Authorized Represen97ve rai <br /> /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 /> 3r 8%0 \Afaconda V4WE 8rook 7 <br /> s OR 77305 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 06 2W 120 Tax Lot#(s) 100 <br /> PROPERTY OWNER: <br /> k Printed Name:klatill I 4 JLtr .A 14_ ‘._41,16r-"-1 /AltgL <br /> Signa e;41(itit 011Z.) <br /> tV Address: 1 Phone "37 7 336 A? <br /> A A <br /> City, State, if,. fie. • op JP _As Fax:/ <br /> t E-mail Address tcy--) ,i , ;1---0,1,6140 COW/ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 1/43 -e 5 K • .e•-•,12,Y1Pr/ <br /> Company Name: / C,11;9/2 j. "sd <br /> Signature: Date: 03/0V2./ <br /> Addres itrirS4 Hi; Phone:5-03- <br /> City,State,Zip S le J.44 Fax: c°3 - 515- SI Oil <br /> E-mail Address jr, a C-- ion rq; cow/ <br /> DEQ License# , t(32.3 C CB# 500/ <br /> GAFORMSISEPTICAS-07 Auth to Apply.doc <br /> MC3-07 Rev 03/10 <br /> SEPTIC 4 <br />