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43 0v67a1F-Ear <br /> MARION COUNTY PUBLIC WORKS ��r <br /> BUILDING INSPECTION DIVISION v <br /> �hle <br /> ED <br /> • <br /> "a"- 5155 Silverton Rd NE <br /> Salem OR 97305 NOV 0 6 2423 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection vgRION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> C fQp� have authorized <br /> ' P o erty Owner/nn(tG( � to act as my agent in perfoiuuing the <br /> (Authorized epresentativPrint 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 /> 075 7 reLS 42- g44 k t't,for O ?7ôz <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 /> Ci44A PROPERTY OWNER: <br /> Printed Name: L; °. € d <br /> Signature: <-44,, CC Date: l t l6,1020a <br /> Address: av15 7 �5c. I� �1 - Phone: <br /> City, State, Zip N✓,f vrG, Of( al 7 OOZ Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIIVE: _ J <br /> Printed Name: f` ��''�11�%'� �� <br /> Company Name: <br /> Signature: Date: /Z5 <br /> Address: I 11 Cn t't I T Phone: <br /> City, State, Zip anAl) O ! 702,0 Fax: <br /> E-mail Address .LGC r&N G1 Tli 7/ e <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />