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ECEInrED <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE - AUG 16 2021 <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MARION COUNTY <br /> EUILDING INSPECTION <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, IA COY o\c L. I`t S 6 r. , have authorized <br /> Pro a 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 /> i -5 Gc.4-4-e, 0.0-A--Irto ) -7314 2. <br /> Pro erty Si us 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: ucty'o clr <br /> Signature: TR Vim" t Date: 1 f 2Q/Z o Z( <br /> Address: et, ton 133 Z 4 (Zia 13ut'##-St M,'Phone: 45D,q 1' L}31 3 <br /> City, State,Zip 9 r o j 4 , Or I /13 b cl Fax: <br /> E-mail Address 1...atl e— i Swwwv1/4 ok.t‘ ( L�t A . C.o 1M <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon r <br /> Signature: /,. Date: <br /> Address: PO B 128 Phone: 503-874-9414 <br /> Silverton, OR 97381 <br /> City, State,Zip Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB # 201683 <br /> G:\FORMS\SEPTIC\S-07 Audi to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />