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' ..,;,, : MARION'COUNTY PUBLIC WORKS• ' <br /> '��� � ����"�' . . BUILDING INSPECTION DIVISION <br /> aill <br /> % - 5155 Silverton Rd NE <br /> Salem OR 97305 . . <br /> : (503)588-5147 Fax(503)588-7948 <br /> • http://www.co.marion.or.us/PWBuildingLispection <br /> . . <br /> . ; i . • ' NOTICE.AIJ O]I�G RJSENTATIVE • . <br /> ` : ' • � / ,I : - q. ••?•o '', • • . ' �.r-' ' .. .. :... . . ,have authorized • . <br /> ' - •, -(Property Oner/Print lame). " . . ' <br /> c' -; :':,,: ) .� ._ ~ .Y,-�‘/G1 - 1 ;: L,:c7:: •to act as my agent in performing the <br /> ._ ..:.: ::. - .(Auth_..rizedRepr sentative I 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 /> • despribed below in accordance with OAR chapter 340,division 071. . <br /> PROPERTY IDENTIFIICATION: ,.. . . • • . . • • <br /> • <br /> - ' Property Situs or Street Address. . . . . . <br /> • <br /> • Arid described.in the records of MARION,County.as: : • . • O'Q • <br /> Legal Description••:• . . Tax Lot#(s). �' . , • <br /> PROPERT'Y.OWNER::. ' • . <br /> M . <br /> • Printed Name: �9�. •a,� . . /yY`e r^/ • .• • <br /> Signature: .. Date: a• 7 - ._ Z O ..-1.... <br /> • • Address; . •333/9 3 ,Ra.l ll-a m J . Ave ' ' . Phone:s°.3 -9 3 /.3) : <br /> City,State,.Zip:69 Tr. . 17,0 . y73�..J . • Fax: . <br /> E-mail Address :4riwec-�a f,-/-P^9i.i6. [iS : <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Ll v\ U,_, 1-)01,P(01:, .: _ <br /> Company Name: . tlZ . . . . • . <br /> Signature: :, Q'"j— Date: . .. 9Imo? <br /> . Address; \N% •H.`901 �rc . i . • Phone: u-Y 5Qe-I 75 3 <br /> . • City,State,Zip '& )( 5::. : •K) OpS Fax • . <br /> Email Address \\p.SS' C c:.@. MU.- "?e;p1Z.• .V,pcy. .• . <br /> • DEQ License# . ' 523O\3 • . • .CCB# . . 9-1 9 I 76- _. • . <br /> 'G:\FORNIS\SEPTIC\S-07 Aitth to Apply.doc ' . • <br /> MCS=07 Rev 03/10 <br /> SEPTIC • 4 • . . • • <br />