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M.ARIO►N COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> `"': "`z>` �•�•••• 5155 Silverton Rd NE <br /> • rH x,p Salem OR 97305 <br /> C-!! . ,�� ?1 • <br /> (503) 588-5147 Fax (503)588-1948 <br /> hst.' ,:. 4 u littp://www.co.marion.or.us/PW/BuildingInspection <br /> NOTIICE AUTIOR1IZIINC i''1CPRES1CNTATVWE <br /> I C S Pi , have authorized <br /> (Property Owner/Print Nan e) <br /> fir-- 4C-6 to act as my agent in performing the <br /> (Authorized Representative/Print a Ze) <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 IDENTII'ICATION: <br /> q_aB liiercreet Rc t_SF,___ r6on�QR_�17 2 - (Shop <br /> Property Situs or or Street <br /> And described in the records of VIARION County as: <br /> Legal Description Tax Lot#(s) c$62$ <br /> PROPERTY OWNER: <br /> Printed Name: rfthjhf_Q 1„ D_, ��; r fl ,�'(,�C�'Peo <br /> Signature:c U� . .!! - Date: ad=202/ <br /> Address: ? Ja,o4i e,#iuDr Phone: ,5-C3 q 31- 1409- <br /> City,State,Zip_r(,af OR g7322- Fax: ,SO;-360-2380 <br /> E-mail Address t gh'e—Q /�-..c1 <br /> AUTHORIZED REPRESENTATIVE: J <br /> Printed Name: 1„_,t1�llut 4W\0% <br /> Company Nan <br /> signature: • Date: 1O-1 - (-.i <br /> Address: PO `qG-' ,L=r.%,7,1 Phone:ED <br /> City, State, Zip_ (,/t<'iv K. ..�"_4" 61•2= `% '' Fax: <br /> E-mail Address r2-'fr: c t:!-) !e a <br /> DEQ License# .:3($ `? ' CCB 44-. <br /> G:IFORAISISEPTICIS=07 Auth to Apply-doe <br /> ARCS-07 Rev U3f10 <br /> SEPTIC 4 <br />