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MARION COUNTY PUBLIC WORKS <br /> ,„1 "';77!.. BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> t7CEL1VE <br /> Salem OR 97305 OCT 1 2023(503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection MARION 0OUNTy <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I li.rrm M. t ra:L ,have authorized <br /> (Property 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 /> 20521 SrrGif Creek- get gE 5 I vt✓to . 012 61738 <br /> Property Situs 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: Mall M. Brac <br /> J <br /> Signature: rn- Date: f/Zi )Z3 <br /> Address:.20 15i76ill Crlek- SE Phone: 5e3-13.7-13a <br /> City,State,Zip Si Itici r1 ( OK g7381 Fax: <br /> E-mail Address Y—ryt bru4Co() m Sn- Corn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon S wer rai LLC <br /> Signature: Date: q <br /> Address: PO Box 1 Phone: 503-874-9414 <br /> City,State,Zip Si erton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683. <br /> G:IFORMSSEPT1C'S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />