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a a <br /> 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:/twww.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I ` / (s&r o.�.�_. have authorized <br /> (_Property Owner/Print Name) <br /> s e A A f c-4 (s t-r 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 /> 5"'7 S'a 17, cr. .r. kJ St <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description S y/vcr (lam 0 -7 Tax Lot#(s) 1 6 a < <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: ir <br /> Signature: £ ,zL g p Date: 4. /01 S 7c? 3 <br /> Address: 3 0 g. Gd o a d rid c, e CY, 5 ePhone: .S o3 -$a - /I P 7 <br /> City, State, Zip ,3z /w U 9 7 3 0 2 Fax: <br /> E-mail Address / e icy/ -fv o s�. 7 7 03 q .M /*/, C a K•. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: . 179SQ~pk hA1kk$)-cO <br /> Company Name: Cpa or R.Jer l orn.g i-.i u(;-f- (IA_ <br /> Signature: Date: 2,(0 —Z3 <br /> Address: Y.O Gux 9 L Phone: c11 2U m Z7 'y' <br /> City, State, Zip S ,./x ,n © . 47 3 9j`� Fax: <br /> E-mail Address4ra O\I is 1-4-An" O vv c .' I , r o <br /> DEQ License# CCB# 2_2 C) 0 C <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />