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6004.,.... MARION COUNTY PUBLIC WORKS <br /> "'iii BUILDING INSPECTION DIVISION <br /> �1 ��`w 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I,DV /Srcec,c_ f ' e. r cz have authorized <br /> n- (Property Owner/Print Name) <br /> AE.0,, E. 1 ,e c•. - r , & \ 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 /> S9 S-1 S.--? Ill _C-- SO,tc,v. oIR % 31 <br /> Property Situs or Street Address <br /> Described in the records of MARION County as:. <br /> Legal Description Tax Lot#(s) <br /> Subdivision, Lot and Block <br /> PROPERTY OWNER: - <br /> Printed Name: /,',uc t- Pier C C- <br /> [Signal 9 Date: l/- y1- 2 Z <br /> Ad Less. S j q;57 �/ 5 cf.- Phone: 503 - C11 L/- 7S`I Z <br /> 1 <br /> City, State, Zi q 73 / 7 Fax: Ai-if- <br /> E-mail Address biz?e,c..piers�0c e,,,,"7 a; I• co pi <br /> AUTHORIZED` REPRESENTATIVE: <br /> Printed Name: 1J U S '+' 4.) <br /> Company Name: 1 f c C�h i Ca I eO t,Yt_+' 4 C..+AA <br /> Signature: e1,.�- t�' ^-- Date: C/I/ �02 �0 ('1 <br /> f , L- E Phone: 5o3 - 9 \ ® 89 1 `T <br /> •Address: ,fn 8 .� �G�°Y1 ► <br /> City, State,Zip ,��td�i-A-}-rO NA. 0 YS q ? 3 ?) 3 Fax: <br /> E-mail Address «S-l-)1A ek r .9-l t.LA" ►'L 0,1 , C 0) <br /> DEQ License# CCB# I at e , <br /> o <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3110,3/18 <br />