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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://www.co.marion.or.us/PW/BuildingInspeetion <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 3 r rt:t l'-(v T G�nS it rl ,have authorized <br /> pe/ <br /> (P ope y Owner" /Print Name) <br /> 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 /> // 3¢s e-ve_rg S i I/6e—r6n OR '738/ <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: p <br /> Printed Name: t k 10 P sir:i <br /> Signature: er -� _Date: 9/9/Z3 <br /> Address: /4445 Ar..�►rcy.. Alt Phone:cO3 . 3 & -1301-- <br /> City, State, Zip S'4e44 I, alt.- 9 7 0/ Fax: <br /> E-mail Address Efr.01-. K.1 o kv sk n C° q maid, cowl <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: f[A 6J <br /> Company Name: PPi& `/ 74vt- Y\ <br /> Signature: Date: °/`�/Z 3 <br /> Address: P.O • //°X Z3 Phone: 5:93'932- / - <br /> City, State,Zip WA/f� C F736 Z Fax: <br /> E-mail Address ft/At/G 7O egc/ otp,•%C <br /> DEQ License# CCB# ZO 8 <br /> G:IFORMS\SEPT[C1S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />