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t h,, MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305. <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> a_F.,t-r4 <br /> NOTICE AUTHORIZING REPRESENTATIVE 1-,— <br /> ZsC <br /> PC4have authorized <br /> (Property Owner/Print Name) <br /> L-z.se_447e 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 /> 5 7 S 4-c ks L-r4 SE -t ,sv‘ae) 91732.g <br /> Proppertr Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description S), 13 Tax Lot#(s) <br /> PROPERTY OWNER: <br /> OWNER: <br /> Printed Name: pv rick c:v-b Sr.A5 C1/4/ 1141 5 'fU.S\ TLY'A-0 LS c� tl <br /> y <br /> Signatur S ,, ,� l��o Date: j ^ - Z7 1-0A <br /> Address: C 7 15 sk L.N SE Phone:,5- 9 3 D 6-E03 <br /> �' !� 2 5 Fax: <br /> City, State, Zip�.trn� V� � -e) 3 <br /> E=mail Address 2 �/v� [ @ a+t. , C <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Se.&* _ N c (..- — <br /> Company Name:A F c-A t o 0 Q&_a r 5 � <br /> Signature: Date: S-1 G- <br /> Address: 3a ; Phone: 5c(t-a5ft- 3 7 c( <br /> City, State,Zip (-� �, C3 lk 97 3'5 Fax: ./('.4 . <br /> E-mail Address Vl nnf: Cep crcc"r` l e G-)e . C c k"-, <br /> DEQ License# 7 q O CCB# 1 k cl Gy <br /> G:IFORMS\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br />