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����,, MARION COUNTY PUBLIC WORKS <br /> 4111 ��i"''' BUILDING INSPECTION DIVISION <br /> ___ `� 55155 Silverton Rd NE <br /> a <q .- Salem OR 97305 • <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, kni6' 2,4d<'L /eI . have authorized <br /> (Property Owner/Print Name) <br /> '3-C 1k a L-t c.w, - 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 /> • <br /> PROPERTY IDENTIFICATION: <br /> /0Z3 • C--1/I Ew aP .d. 5'E Lich,5 6 - 5/' 3 <br /> Property Situs or Street,Adci'ress . • <br /> Described in the records of MARION County as: <br /> Legal Description 715 R26 Sec 0 Tax Lot#(s) /00 <br /> 1 Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: kAREA/ Liel ,t ( . <br /> Signature: ea.)1 41. 42144 Date: Ch 20 -26) 2 3 <br /> Address: 230'(7 t3 1 *0 a 2 LAB Phone: ) --` E,5 9.ii--0 <br /> City, State, Zip /J_y0,� s CS i2 _ !7 3 J Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: aZ K.,� • t >"rc i w el ? <br /> Company Name: <br /> Signature: 9_ ��� � Date: r 2 -- 0''z3 <br /> Address: 23( l Z� A1 2 2.01-7- Phone: 3 "B 5 T✓L/ ,„ <br /> City, State, Zip Ley Oil . ) ?3 coe) Fax: <br /> E-mail Address / <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />