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MARION COUNTY PUBLIC WORKS ' • <br /> ' • BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://vvvvw.co.mation.or.us/PW/BuildingInspection <br /> • NOTICE AUTHORIZING REPRESENTATIVE <br /> . . <br /> • • 0 4./.1 /V.P- . : . ,have authorized <br /> r— (Property 0„.N.xner/Print Warne) <br /> ,_cm,/g. )1.8 14 tO act as my agent performing the <br /> : * (AuthOizedRepr sentative/Prnit_Name) <br /> activities neoessarY to obtain site evaluations,permits, and other onsite wastewater treatment program <br /> services provided by the Department of Environmental Quality or CO-ft*Agent on the property • <br /> described below in accordance with OAR chapter 340,division:071. <br /> PROPERTY IDENTIFICATION: • <br /> • 3 3 e q..)) 0• Ve 7( k_ <br /> • j <br /> • Property Situs or Street Addres§. <br /> Arid described in records of MARION County as: - <br /> -Z a u <br /> Legal Description. . . • : • . Tax Lot#(0 J . <br /> • <br /> PROPERTY OWNER: • <br /> Printed Name: fr)• <br /> Signature: Date: a <br /> • A.ddre&i: 334(93 At9q/1i--00 AVe Phone:5.° 3 3 °. <br /> City,State,Zip 6 9 ir °k <br /> 77'3 6' Fax <br /> • <br /> -mail'Address , e r?-r-7').11 91-4 <br /> • <br /> • <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: M4\1-1,, ON,P(CA, <br /> Company Nathe: \-1-1- <br /> . 0 <br /> Signature:. Date: 6P91,1).-''2-- <br /> Address; NU).1‘..b C (WAY\ 9--A Phone: 6-5 3 <br /> • City,State,Zip IY.CcOIS orpobc) Fax . <br /> E-mail Address )LSS% C.0% ot. `- •erp - Q.,OCYN • <br /> DQ License# '252? v3 • CCB# 9 st5 <br /> ,G:\FORMSSEPTIC\S-07 Alith to 401y.doe . • <br /> MCS-07 Rev 03/10 <br /> SEPTIC • 4 <br /> • <br /> • <br />