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MARION COUNTY PUBLIC WORKS I <br /> JUN 1 6 2021 ..J <br /> No! BUILDING INSPECTION DIVISION <br /> 5155.Silverton Rd NE MARION COUNTY <br /> Salem OR 97305. BU LDING INSPECTION <br /> (503) 588-5147 ';Fax(503) 588-7948 <br /> http://www.co.marion.onus/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, �G nY\6r\-'r)_— B 1 r\ - ,have authorized <br /> (Property Owner/Print Name) <br /> 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 /> 14S 440,)Je S4 - a4ir0i�- 1Ca_ q7-n <br /> Property Situs or Street Address <br /> And described in the records of MARION County as:Legal Description cf Q Y\ �Q 1'P u11t<< 11/1oc C✓Q '/ Tax Lot#(s) R qgSg 2 <br /> U ot& <br /> PROPERTY OWNER: <br /> Printed Name: .CGdiGtN (yoLAJN_ <br /> Signature: Date: 517.// Z <br /> Address: ( -LC Phone: q 7'I ' 76 -- zio1 <br /> City, State, Zip Jk. 0 4( O 9 13 C C- Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: <br /> Signature: Date: <br /> Address: Phone: <br /> City, State, Zip Fax: <br /> E-mail Address <br /> DEQ License# CCB# <br /> G:WORMSISEPTICVS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />