Laserfiche WebLink
COUNTY PUBLIC WORKS J EICE [IV - <br /> MARION <br /> BUILDING INSPECTION DIVISION JUN 112021 <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 BL ILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, have authorized <br /> (Prope y Owner/ rint Nam <br /> ra•� Zsu-� 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 /> -72_yZ (Lv— (LA <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: (' <br /> Printed Nam . <br /> Signature: Date: 64 a/ 202- <br /> Address: _ �i A vase Phone: a 3, -- Z ' 7 a <br /> City, State, Zip Sf. P„ l Qy-` 97 /3-7 Fax: <br /> E-mail Address• <br /> Z�,,., <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: L�,,�_ -u,►.� <br /> Company Name: <br /> Signature: TV., Date: � /2o-t <br /> Address: vn Phone: S-6 3—5/g- r7 2.7-7 <br /> City, State, Zip S+ • i9..v / cw-- 97/3'7 Fax: <br /> E-mail Address /hrzbi r 04,3 U Q'h-i�., /• C®�- <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />