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, i <br /> �,,,,, MARION COUNTY PUBLIC WORKS cl Q <br /> ,'' '',,��� BUILDING INSPECTION DIVISION <br /> . %`� �� 5155 Silverton Rd NErn <br /> JUL13 2021 <br /> MARION COUNTY <br /> i <br /> ,�, Salem OR 97305 <br /> (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Suildinglnspection BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, -1\i ke r 5, mestizo ,have authorized <br /> -q weer/Print Name) <br /> /44 kr-f46-j - a n n 40-e" to act as my agent in performing the <br /> (Authorize('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 /> 206.27 47e , 4, v-,„-e._ , ole.._ a <br /> g7oa <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 0 4// W /3 C— Tax Lot#(s) CC) ®0 <br /> PROPERTY OWNER: <br /> Printed Name: _ k L/'C- <br /> • Date: Z.A,i 1, 2v1\ <br /> Signatur <br /> Address: (0 3 H Phone: <br /> City, State,Zip04-- g7®02- Fax: <br /> y �U�w� ►�m. � <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 0 A a eiPr- <br /> Company N V-el Otal(04-e 4-11I e"V <br /> Date: 0'7 - 0'7— <br /> Sigma <br /> Address: P. o . 7/ Phone:503 3 1/7 rr J <br /> City, State,Zip /�,t � v-�1 a . Z- Fax: <br /> E-mail Address /---G.rvc� Q .sc-o AEA C€ -ecc , C.0 <br /> DEQ License# _ _ . CCB # <br /> G:\FORMS\SEPTTC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 4 <br /> SEPTIC <br />