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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION a 3-ts����� <br /> -,am_;,,.'��� 5155 Silverton Rd NE <br /> Salem OR 97305 c� w ip <br /> D <br /> (503)588-5147 Fax(503)588-7948 APR 1 8 2023 <br /> http:/Iwww.co.marion.or.us/PW/BuildingInspection <br /> - PMArRION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, <br /> \J -wt,i~5 M . So C j j-s:-)E t have authorized <br /> a (Property Owner/Print Name) <br /> ASt`J S,p Nc_ -y r._.Q_, to act as my agent in performing the <br /> (Authorized Representative 1 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 /> MG,30 Q tdo t.t�-00C1 SG £ it - a g'73G�, <br /> 1 Property Situs or Street Address <br /> Described in the records of IvIARION County as: <br /> Legal Description 7 y Q 310 Su. 2 141) Tax Lot#(s) 2500 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: 13-714ES�`� • 3 O Lt R.t'ET—' <br /> Signature: WWI, /- X 1 44 Yr� ' Date: 14- `/ . 3 <br /> Address: /a?b a p R! elQ¢�o R ..5i s Phone: 5&(t- 3 a 7- 3107 V <br /> City,State,Zip %.1 Cralfe-YSoh I Gl7 3 E a- Fax: <br /> E-mail Address bout-del-3 O f&Z.(3'ill a; ( • C-.%'01 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ✓N ' 6 ot,A. c.C-V-- <br /> Compan A r- V i C.e <br /> Signa Date: 4- ! 41z67...3 <br /> Address. s• 41'"4- Phone: 5141-1324- O SSS I <br /> City,State,Zip A tbant3 4 en/a C1"1322. Fax: <br /> E-mail Address A- e_ Se.- CC. ') v\tebyNo.i1.CA►Y1 <br /> DEQ License# 3 S 1n- CCB# 1555 g I <br /> G:\FORMSISEPTICS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />