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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE ( <br /> -Ein) <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 - IOCT 16 2023 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZ NG REPRESENTATIVE <br /> � ' U9- 0n1) <br /> 1 I, 5 s�e �OYa�► 0/9q Torah ) ,have authorized <br /> (Property Owner/Print Name) <br /> (7h 11/f ,a raf y► 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 /> 12 9'11' dG /c hem Pr /1/r Qia 97026- <br /> Property Situs or Street Address (b tom <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER:Printed Name: i e 9,e J T 6,--o h , U a T ray! <br /> Signature: GG* Date: /0' - 2 3 <br /> Address: 12 q q c9 I< Phone: TO 3— rd- ��y/ <br /> City, State, Zip 6erVC 5 OP, 7 '702c Fax: <br /> E-mail Address 0 I,a -fora n � m a/ 1- con,' <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Pie' '/l i f /ara ' <br /> Company Name• !oro'n 7/2 S C 5 / ( L <br /> Signature: Date: ' ' 7 '" 7 '3 <br /> Address: /2 �"� Re k heel Pr /v F Phone: -7/— ��6-` 9'2O 3 <br /> City, State, Zip 6erval OF 17D 2c Fax: <br /> E-mail Address "tor ail , 17///P j 3'i 1/7 <br /> DEQ License# CCB # <br /> GAFORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />