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0,? ,t3D4-193a <br /> . , <br /> .... . , <br /> . : <br /> • <br /> , • . i <br /> .,0041,2,4"...17- . -MARION COUNTY PlUBLIC.WORM BUILDING INSPECTION DIVISION <br /> 5155"Riverton Rd NE <br /> ---------.7.------; <br /> Salem OR 97305. <br /> (503)588-5147 Fax(503)513/3-7948 <br /> . - http://mvvy;co.mariim.orma/PW/Buildbx&tsPectiPn <br /> OM 1 1 <br /> • i <br /> NOTICE AUTHORIZING REPRESENTATIVE* <br /> .6 -1-7 - frdtki 6ic 5 1-1-C--( ceft,a..1,, ii.....,.,1,—7 ,have authorized <br /> (Property Owner/Print Name) <br /> -14-<_ 14,,_-",r --1,?.;e-Li..."}5.....-- th.act aS my aggiitihpeifortaing the. <br /> (Authorized Representatiye/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 Of County Agent.on the prOcity <br /> described below in-accordance with OAR chapter a40,division 071. <br /> PROPERTY IDENTIFICATION: . <br /> / 54W-6 _01.teill Ad cili)€(.&" .0 4. <br /> Property Sinn or Street Address <br /> And describedin the records of MARION County as: <br /> Legal Description. e 7 IF. 4 c Tax Lot i(s) Q 0 L <br /> • 0110PERTY OWNER: . <br /> •I Printed Name40: i' 1 • pc 17,fe`trC,J <br /> *g &Vulture: 1:0"....... . . . Date: 67,2 V;J . <br /> ii.Address:33 Si 0 ft 4t titaii f2d kw. Phone:.503 --47S-1- 7Y7y <br /> Ithy,State,Zip SI tar o_k r730 if Fax:. <br /> •itie-mail Address So tt th f 00F;ty it(..•@.,inqa I C.OM <br /> AUTHORIZED REPRESENTATWE: <br /> 1 <br /> Printed Name:. L...:5....ar, <br /> Company Name: ASP 44-&,..6 Le . 5 eRk--,:c S y 5-ke—3 <br /> iSignatUre: aKi--- .Date: 7-.5 i-0.3 <br /> Address: 3 a/‘-t.5, (-5S G c—,54,e, e-J. Phone: 6'it- //0- 177 1 . <br /> City,Statei.Zip Le...loA."4., G e- ,9 73 s . Fax: <br /> . I <br /> -inail Acklress An 4,olc•1/2 ...E.'Cat-AA 61.e 6 CIA-IC-% - C --1 , • • . <br /> DEQ License# 3 7 / o S. . CCB# g tile, <br /> OFORMAISEPTIOS-07 4111 to Apply.doc <br /> PACS-07 Rev t3/10 <br /> SEPTIC 4 <br /> 1. • -• <br /> ... .... <br /> 1 <br />