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MARION COUNTY PUBLIC WORKS [4 JU i` 01 Z023 <br /> BUILDING INSPECTION DIVISION <br /> - �—` � 5155 Silverton Rd NE eQul rrY <br /> Salem OR 97305 BUii7C:fiNG [NSF3ECTIONJ <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I,1 Ju . L,r„z )-c ivns .lam c_ War I a2)Trtu.g&r- p"�,have authorized <br /> (Property Owner/Print Name)V <br /> Josh Hansen ( Oregon Sewer& Drain LLC) 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 /> 11 si 3 s el ak,S,or, s Qd vssecAae ceNo <br /> PropertySitus or rss <br /> And described in the records of MARION County as: <br /> Legal Description 07 r uJ 050600300 0 Tax Lot#(s) S-Gai 13 (zux') <br /> PROPERTY OWNER: <br /> Printed Name: 10- L„`ha.. f'c.rMs In <br /> Signature: �� 1?c c Date: 6-a c- a 3 <br /> Address: 474/1 er..s/L Cr.eJ( Phone: S-03—9s,d--/9VS <br /> City,State,Zip t(u cr14,., 0� 9 ?3�r Fax: <br /> E-mail Address kw-1 e 6I /r r#n c . -c— <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore Se r& Drai LC <br /> Signature: • Date: 5 Z� <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!FORMSISEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />