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• i (93,0 — <br /> ���� MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION D ECIMEB <br /> 5155 Silverton Rd NE -� <br /> Salem OR 97305 - OCT 2 0 2023 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspectioItlAipION COUNTY <br /> • BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> pa I2 AI4" have authorized <br /> (Property Owner/Print Name) <br /> Gn7' K4K-(Mate f C U fietigit o 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 /> 232 1 roa. r F^/A vC.ly LvA v S. S,a c.E,/ de. c %).2 a 2 <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: ou 1Sc-E ) P2aPE4 l/C.S £ LG <br /> Signs Date: <br /> Address: 7 y S A-7 E sr' s 6 Phone: 4'63 =3 70- '/6 <br /> City, State, Zip SA LE^t., p 2 ct .?/ ) Fax: <br /> E-mail Address ke,1r-0-- LaK-er"Qn. Aef- <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /ten,-f Kc -(',QA / C UP r 0 <br /> Company Name: /-F-a <br /> Signature: ate: /6/1/2,3 <br /> Address: S 97 .sr.4 sr se Phone: So3- 932- -) <br /> City, State, Zip S,1 LCn-‘, v . q)3/> Fax: <br /> E-mail Address ke."'t' a 16 0e,an, "`-t- <br /> DEQ License# CCB # SS f L/ <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />