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if <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION C -E <br /> —7.7 5155 Silverton Rd NE -7Th-) <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 - JUN 2 9 2023 <br /> http://www.co.marion.or.us/PWBuildingInspection MARION COUN V <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, J G+.:"-rt e.,. A O-t-r- ,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 /> gj2I O,.-- Ana ., c-teA,L. <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description © 621 If1 11 ACJC zoo Tax Lot#(s) Li06 <br /> PROPERTY OWNER: 2 <br /> Printed Name: I-0.�r L.cr- 1.) a, <br /> Signature: / I J c✓ — Date: 6 / 3 <br /> Address: V-I At I S 1-rsa I G-v r-c /)r A Phone: °17 I- ac 8 - S S t 3 <br /> City, State,Zip 5 a- OR- (A7 3 0 . Fax: <br /> E-mail Address e M a; . LO <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon ain <br /> Signature: Date: <br /> Address: PO Bo 82 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\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />