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7 <br /> MARION COUNTY PUBLIC WORKS 4-s -60 ,g�- /mod►/ <br /> IIIII <br /> ii BUILDING INSPECTION DIVISION (( <br /> ����1�. 5155 Silverton Rd NE Y5 C E _ V <br /> Salem OR 97305 <br /> EI <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection JUN 012023 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> ',Si& Lary/ /—ramPoll la gar I a i-..t i k r- Pl. ,have authorized <br /> (Property Owner/Print Name)LI <br /> Josh Hansen � Oregon Sewer& Drai <br /> n LLC) <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 /> II51.3 SeIck.S r, 5 s 2a we_a itsa3Sel�S d Nc <br /> � <br /> � s � <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 071 i ii0,5000a300 Tax Lot#(s) s -I8 (zuxi) <br /> PROPERTY OWNER: <br /> Printed Name: It. L,`h i 1'c.r m s Ti..� <br /> Signature: ,,,tia Pfr_c Date: 5-a S- as 3 <br /> Address: 4/74-11 arJs/t 6r a.21C 61-- illy Phone: &D3—9302 /9 V3 <br /> City, State,Zip �;Iu crrgl, Of( 9?30 Fax: <br /> E-mail Address )ar I e.&w L,i..e./-zrgr,s.h.c_ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore Se r& Drai LC <br /> Signature: Date: 5, 5 Z7 <br /> Address: P ox 2 Phone: 503-874-9414 <br /> City, State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 <br /> G\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />