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I <br /> ,041-ki.„ MARION COUNTY PUBLIC WORKS af E (�(� /7 <br /> EU <br /> '.n♦ <br /> e BUILDING INSPECTION DIVISION �L �I V <br /> ��il`< �� 5155 Silverton Rd NE " MAR1 <br /> 7 <br /> -"x`""`� - Salem OR 97305 2022 <br /> imi (503)588-5147 Fax(503)588-7948 �� COUNTY <br /> http://.www.co.marion.or.us/PWBuildingInspection 3UILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> `f \(A./ <br /> have authorized <br /> I, VaSl kc4 ✓� <br /> r (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 /> MO Rv * 3 r . I J_J-r Dc <br /> Property Situs or Street Address . <br /> Described in the records of MARION County as: <br /> ,,�, J � k m;4 �o4-- s Tax Lot#(s) ' .. <br /> Legal Description ��..�, a � <br /> Subdivision,Lot and Block t31ccc t5 <br /> PROPERTY OWNER: <br /> Printed Name: ,I ,ro <br /> / <br /> Signature: Date: 31-2 z. <br /> Address: (/ 7eeoolot.. I�o� di-- Phone: 03-Yrsr/-72°D <br /> City, State,Zip ,5,�.�-, , <br /> a.c. T 7 30 5— Fax: <br /> E-mail Address i i,// nn,/,/i/ ei m alt(a kll . <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 6 /ice,,,f Now,5 LLC , Pokc c:. - <br /> Company Name: '5‹[ i c..fi 14e C- S 1 L C 1 • <br /> Signature: ��� Date: AA“.e_L IC 1 2 O 22 <br /> Address: 10 I 13,r8n ki es. l c Rol N I , Phone: 57O7—cg7/ _36O C) <br /> City, State,Zip $41 c v✓. a v-. S 7303 Fax: <br /> E-mail Address -r,, k ce.,4 vvl&J y,,.r 4'r . o <br /> DEQ License# RI .75-5 ? 1 2 CCB# 2(53 3 7 <br /> G:\FORMSISEPTICtS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 • <br />