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t,„�,; MARION COUNTY PUBLIC WORKS <br /> ``I "'" BUILDING INSPECTION DIVISION <br /> ---1✓j��` �, 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Ma 4. ,have authorized <br /> (Property Owner,/Print Name) <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 /> }aqact i%Ues-ton ( d wE v e-1-119n, o 973Lk <br /> Property Si:jus or Street Address <br /> And described in the records of MARION County as: <br /> Legal.Description Par r)'`MV 33>)ool000 Tax Lot#(s) * <br /> PROPERTY OWNER: <br /> Printed.Name: Mane. -I"s d M <br /> Signature: "t M Date: .6 + a <br /> Address: P. 0 SO 83'a Phone: 6-0 3—9 3 a- 35-344 <br /> City,State,Zip 311 V eT all OR 7 732 t Fax: <br /> E-mail Address ,5+2d e s Po l4 e Q <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore er& Drain <br /> Signature: Date: 7-4-47,P ox 282 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 ISEPTIC`•S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />