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MARION COUNTY PUBLIC WORKS <br /> .4,1444;111„... <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE C. IAYTtll <br /> ------- le47.00' Salem OR 97305 i I 1 1 <br /> (503) 588-5147 Fax (503)588-7948 i <br /> http://wwvv.co.rnarion.or.us/PW/BuildingInspection <br /> MN V1014 18 2022 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, 0/ /5.5CE1)SliCal )i Se-e)1 '17(j have authorized <br /> (Property Owner/Print Name) <br /> rYte id- ce.-4{-e--C" C'l 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 /> • / -S.1"& I-4 t-tp•/ 2,-2- S E idozsp(40- 1 ciz 973-5-' <br /> Property Situs or Street Address. <br /> Described in the records of MARION County as:. <br /> Legal Description x\A-, Tax Lot#(s) A)A <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: <br /> Signature: )/1-Le....exxi„4,../.......)- ' <br /> 4/71 Date: I / )/6 /7-7 <br /> i <br /> Address: p e 50)4 927 -9-4=3:er-1-- Phone:6'6 3) I 4144- <br /> City, State,Zip 54 teivi 1 A,k f 7 3 of Fax <br /> E-mail Address -1A1,9 t ea cf-@ it-Y7 f) r) . co <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ry-R cl- -PeA---14€0$ Orl <br /> Company Name: F4.0.,4 et.— -tee4 hpti b`t•ph <br /> Signature: 1,f4 14.....et ____ <br /> Date: / 1,- /5" - Z. <br /> Address: 5-"PZ_ 4 :.4 coh-r S t". Phone: glS 983 s s / <br /> City, State,Zip S;I lie eiv vi etz._ 7 7 3T1 Fax: <br /> E-mail Address C pfa-441- r5t,s1 E Lie . (-40kri <br /> DEQ License 41 59, .Q1 Q CCB# <br /> MFORMS\SEPTICIS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 . <br />