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giR- (56-1551P <br /> MARION COUNTY PUBLIC WORKS <br /> 1)11 ( -E[ VE <br /> filMORki <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 U AUG 18 2022 <br /> (503)588-5147 Fax(503).588-7948 MARION COUNTY <br /> www.ep,marion.orms/PW/Bnildinginspection BUILDING INSPECTION <br /> NEW <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 6,\1\% 1.4I,..ify)ae-, A) ,have authorized <br /> (Property Owner 1 Print Name) <br /> COA.I C- to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessau-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 /> 12.S Pa DL,ti- \)- <br /> Property Situs or Street Address <br /> And described in the records of MARION County as <br /> Legal Description. Tax Lot#(s),_ <br /> PROPERTY OWNER: <br /> PrintedName: 1\4 sloGle")9(,QA 0-rrae..11N, <br /> Signature- - /1,*"/:/ , iiiPi Date: a- - 22 <br /> Address 22,9 Phone:'33 327;1 115 <br /> City,State,Zip (Ye-- 9 "1 7 Fax <br /> E-mail Address j /11 ,-t,e„ VJ c2 4ejvC t-V1.00 LADni-N <br /> (Ao <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: bQ. 1.&_) C L- L't ez- <br /> Company Name: 0,..) p,3 STR t.) Cri t G. <br /> Signature: Date: ( 5-77t- Z <br /> Address: Po g //5-0 Phone: co - 9e79 /&34,7 <br /> City,State, 6-pf q 2-30—7 Fax 5;9 0 (fi 1s-76 <br /> E-mail Address /32 .1,.i 01(.167 edi2rtinze 170,- ,/)e (9 <br /> DEQ License# 3537 CCB# <br /> CiAFORMS;SEPTIC‘Application Packets\S-07 Autirto Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />