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23-00 33oviH- <br /> ���� MARION COUNTY PUBLIC WORKS ��/ <br /> '��I ����/�,'� BUILDING INSPECTION DIVISION D E C E v <br /> III' <br /> ED <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 - 1 O 2023 <br /> ��G <br /> http://www.co.marion.or.us/PWBuildinglnspection MARION COUNTY <br /> BUILDING INSPECTION <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 0,1M U zekk6. 'S , have authorized <br /> (Property Owner/Print Name) <br /> V‘ACkitt rAitAlkvITU'At <br /> taato 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 /> Property Sims or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: ak \ik)2U.- 6)6 <br /> Signature: t 'z{ _Date: g-r-{- <br /> /a-s <br /> Address: VY t-r1 n� gun rk Phone: C5t2 tj 59 - 1°I O <br /> City, State, Zip 2l,rvaiS 0 Q °I1Ot - Fax: <br /> E-mail Address W 2c1.klnorS i I . ( w1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: NIA W2✓y <br /> Company Name: mtt$ Movtlown\ NASimaic�n <br /> Signature: Date: S - 011-2 0 23 <br /> Address: Phone: 5 0 3.- 13 2 -3 O S I <br /> City, State,Zip Fax: <br /> E-mail Address <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />