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0'�h,,1191j` MARION COUNTY PUBLIC WORKS ' a V <br /> F � 11 BUILDING INSPECTION DIVISION <br /> ��%%`-. �� 5155 Silverton Rd NE J <br /> Salem OR 97305 OCT 22 2021 <br /> ::zi (503)588-5147 Fax(503)588-7948 <br /> IIIARION COUNTY <br /> http:/Iwww.co.marion.or.us/PW/BuildingInspection BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, LT Ca st e ro v' ,have authorized <br /> y� (Property Owner/Print Name) <br /> f 1,,n erl em Widergroundj L to act as my agent in performing the <br /> (Authorized Repsentative/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 IDENTIFIC <br /> ATION: <br /> q i Iv ILO set f i JIs hie.se fuirnkr, Ole °!7392, <br /> Property Situs or Street Adress <br /> And described in the records of MARION County as: <br /> Legal Description lee leeld pY p 4.SM arc( Tax Lot#(s) D q1 a,Wi g go 0 1100 <br /> PROPERTY OWNER: U <br /> Printed Name: 1 f 6.{ y � <br /> * Signature: Date: I D i 5' a_I <br /> Address: 391(9 cpf ffiii5 bit. SE Phone: C57)3)971 -2760 <br /> City, State,Zip Twrntr, )le . ' 7 3 qL Fax: — <br /> E-mail Address Iiyhtifbrresfe a,iYltrOi i 6) <br /> amr4l. C°m_ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name:_qa$1, k f n p Company Nam Are uui 11,h 0 J P,1".9 <br /> n ' aids u t, <br /> Signature: -�� Date: [0- I5-a I <br /> Address: P•0 ✓y i ii Phone: Ng) (QR7-zip <br /> City, State,Zip Uloia`Yhtfy, (X 97 5 Fax: OW 6W7-g-134 <br /> E-mail Address. w <br /> Pm i (a 44tv1w'rial tom►d�✓��:ur�11I6. cam, <br /> DEQ License# 3q3 f CCB# a06255 2- <br /> G:IFORMSISEPTIC1S-07 Audi to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />