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���� MARION COUNTY PUBLIC WORKS <br /> 'ilI 1���liN' BUILDING INSPECTION DIVISION <br /> �1 5155 Silverton Rd NE C) EC. E v <br /> En <br /> m Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 L AM 1 ?�� <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> MARION COUNTY <br /> • <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I; 7. 4 Nati/eeI have authorized <br /> (Pro erty Owner/Print Name) <br /> ,/&,// fya veeV 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: J / /. <br /> R <br /> / 0 6 3`f k-40--- 6-,-o ve /U iV 6(4.D r� L or'? 1 n, 9767 / <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: /Pi q a eeV i <br /> Signature: y L-',..,✓ Date: k --4/- c <br /> Address: f 3 4 ,fAlg Phone: Soy - 73-0... - 7; 7 Z— <br /> City, State, Zip /,t/o G)L dui. a_ 970-7 I Fax: <br /> _ E-mail Address 2L'ef y ai m q+V eev64)y niAt /- CO B <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 4-, /a el I 1 a f Ve C V <br /> Company Name: AO- . <br /> Signature: Date: '- /3-Zo z--3 <br /> Address: /.067 Y 4,‘w Avr_ ,ed) �� Phone: f 67 —S4/r'--.7°`/Z-- <br /> City, State, Zip /a D c 6VK t 04, ,7D7/ Fax <br /> E-mail Address an A h J.i1'I / v4ao/CO'kz , <br /> DEQ License# /1f, -- CCB# 9`9.- <br /> GAFORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 . <br />