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• <br /> �" •,� MAR1U 4•CUVIN 1 X 1'UBLH, W V.t <br /> ,it !�,,,,fr,,,, BUILDING INSPECTION DIVISION <br /> • ii•iii._-.iA.1.....i..-.... r :. 5155 SiIverton,Rd NE <br /> - ; Salem OR'97305. <br /> ....„.. ... . . <br /> . ., (503)58&5147 Fag(•...., 88 7948 <br /> httpllwvw .ro.marion.orrusfPWBuiidinglnspecton <br /> • <br /> NOTICE NUM. 00RIZICNG REPRESENTATIVE <br /> 1, Cln. W. I:l1 ss::. -. ,have.anthem <br /> (Property Owner/Print Name) . . <br /> j `G c_.J to'act as my,agent"i periosrriir <br /> . (Authorized Rep esentatrve/:Print Name}_ <br /> activities:necessary to obtain site"evaluations,permits,and other onsite wastewater treatment p • <br /> services provided by the Departu ent o Environmental it uatity or County Agent on the proper <br /> J descnbedbelow,in accordance wi h OAR chapter•340,.division"071 <br /> PROPERTY <br /> \ • <br /> W w..=mot. . 4 ';'- 'f).a - SDK- 134 <br /> Pro e" Situs or StreetAddress'' <br /> P �Y <br /> And described;i tthe records of:=MARION Coun as <br /> Legal Description - _ ., .•�, . Tax Lot n(s) <br /> PROPERTY OWNER <br /> • <br /> P inted Name• J. I,r+c4 .. l Ci ` <br /> Sign, Da#et3'l g3'.. <br /> Addres . ✓t 54 .:1". 'Phone <br /> City, State,Zip _ l • Fax <br /> E-mail Address <br /> • <br /> AUTEIORIZED REPRESENTATIVE:' = <br /> Printed Name "`'t V`"iwr� <br /> CompanyName: :.�% , *{•i.0 <br /> Signature Date.• •it25 _ <br /> on : St✓ -'tbZ_Address .l3 ;6CX 1 {G( , <br /> City,,State,Zip . qL ,,Lsa t l o O .. rj"7 32: Fax <br /> E-mail Address • [_Dw6 � ii cry. <br /> L)EQ License# : °I 1' <br /> CC.B# 62,2- 7 <br /> • <br /> K pAd <br />