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4 ,, MARION COUNTY PUBLIC WORKS <br /> 01 "� BUILDING INSPECTION DIVISION <br /> ~%l�� 4 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, SV& / 3.e/ -' ,have authorized <br /> (Property Owner/Print Name) <br /> Josh Hansen ( Oregon Sewer& Drain LLC) 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 /> 9 Z . („5E -ti-�a - i <br /> Property Situs or et Address <br /> And described in the records of MARION County as: <br /> Legal Description .5' -7 Tax Lot#(s) 8. / L + /kp <br /> PROPERTY OWNER: �•-iPrintedName: / ha / Appa 5er ( 57L / <br /> E' <br /> Signature: yam--- VIZ Z m'ii��1//0' Sw'' Date: a� - 6-- -/ <br /> Address: �i ✓EY ,[ /�5 j'7r—!.Jl./ Phone: S03 . 'l 9 9. 19�/ <br /> 4 City,State,Zip , -t i '7.5 V/ I�_ O R. y 7/3 a 5Fax= <br /> E-mail Address .5a.."- yy)C S S..e,Y' P 9/�Q,/ COsr) <br /> J <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Names: Orego we & Drain LLC <br /> Signature, "W Date: CZ•OS•2.62-l <br /> Address: P. 82 Phone: 503-874-9414 <br /> City,State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer_com <br /> DEQ License# 38968 CCB# 201683 <br /> G:\FORMSISEPflCCS-07 Auth to Apply.doc <br /> MCS-07 Ray 0$!10 <br /> SEPTIC 4 <br />