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1 <br /> MARION COUNTY PUBLIC WORKS <br /> 4 BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE rtEC7NLED <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MAY 11 2023 <br /> http://www.co.marion.or.us/PW/BuildingInspection MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I A, ifk0m have authorized <br /> Property Owner/Print Name) <br /> DAJ cl M.o Rom e S 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 /> CL ch 5+ �l��d�a , 0 k, g7360 <br /> Property Situs or Street Address • . <br /> Described in the records of MARION Countyn as: <br /> Legal Description t✓cce 127Ogt t'.�L gob Tax Lot#(s) t 700 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: • <br /> Printed Name: A +hoiu MoP-emie <br /> Signature: 1111:21-)6•11\2.. _ Date: el ! ,30 r Z 3 <br /> Address: US' (,kj S+ S B- Phone: VS—8'cii `Z 0'Q <br /> City, State,Zip V cn 3 Fax: <br /> E-mail Address -k-, MOM( Co .4 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: D/t,V 1.1 AOR.ove <br /> . Company Name: CAN y0 iv C A/.i Rkcfic,v <br /> Signature: Q4 ( Date: 2-7-(23 <br /> Address: L7C W i t Io w 5+ S E. Phone: -777 5-7 I-%LI/ <br /> City, State, Zip •T ci.ex AAA "7 3 S0 Fax: <br /> E-mail Address (ZiUeZ UW WJC_O,S-}Ruc+iorJ(9 *IA . COM <br /> DEQLicense# - CCB# 2.1430+L1 <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />