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r /Y3r001-1 \7V�. <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> nn: <br /> 5155 Silverton Rd NE <br /> Hui x Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, \te v\ S v l\wo" have authorized <br /> (Property Owner/Print Name) <br /> )eP\v C\ Sc\ . 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:14b �C� C P- �bWS,Okk Cv c 17 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 O r-`WNER: <br /> Printed e: eNevN S \\‘‘vth <br /> Signature: , J.411 l,)112�„ Date: 5:3"7--3 <br /> Address: -79?A \vs 'A Phone:56-3 <br /> City, State, Zip N S ,'Xt 0 f 1 T Fax: <br /> E-mail Address A_ <br /> AUTHORIZED REPRESENTATIVE:15,A <br /> w` <br /> Printed Name: c cx, te\ ,A <br /> Company Name: <br /> Signature: i-� � Date: 5-3-73 <br /> Address: e5 08 Phone: So3 - Z Eq /4 c ti <br /> City, State, Zip AV C i\`2 ©f C1 325 Fax: <br /> E-mail Address App".Sk� 'e Jt - - (coin <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />