Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> .v- Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, go6E i?V F. ,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 /> I LI 1 t 3 4lpL„-d- r cum 1/ --1 6t2 ?7? 1 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Lot <br /> Legal Description Tax #(s) <br /> PROPERTY OWNER: <br /> Printed Name: e,i3E F 2o1'E L J <br /> Signature: 2 i d —77 I4 (tom., Date: /(/i 7/2 <br /> Address: /41(3 © -(i— o . Ju E Phone:5•4_ 6, 7 347 <br /> City, State,Zip Si Lift r2.`7z04 Pit, ` 13 1 Fax: <br /> E-mail Address V`('O-�� ~J �' g tvz a1 I. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon Sewer Drain LLC <br /> Signature: Date: j1 �Z-23 <br /> Address: PO x 128 phone: 503-874-9414 <br /> City, State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.corn <br /> DEQ License# 38968 CCB# 201683 <br /> G:1FORMSISEPTIC\S-07 Auth to Appiy.doc <br /> MCS-07 Rev;03110 <br /> SEPTIC 4 <br />