Laserfiche WebLink
01/4 —tom (3'51p <br /> COUNTY PUBLIC WORKS MARION 1EC <br /> BUILDING INSPECTION DIVISION <br /> " Silverton Rd NE,���_,, 5155 s I OCT 18 2023 —) <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MARION COUNTY <br /> http://www.co.marion.or.us/PW/BuildinInspection BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, I(rly M. t raoLl , 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 /> 20524 �n(.�G�L Creek- M5E <br /> o ' 5 ls!tVus o tr). tZ. g73g <br /> Perry <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: Karen M• •racii <br /> Signature: ' )2L4 f' Date: f/2i /23 <br /> Address:2os21 5114 Crtk-Rol 5C Phone: 5123-939'93 ZS <br /> City, State,Zip Sl IUD r) / Oi( q75`t'i Fax: <br /> E-mail Address k rrt brad co iYiSh- Corn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon Sewer& Drain LLC <br /> Signature: Date: e -oZ9% <br /> Address: PO Box 2 Phone: 503-874-9414 <br /> City, State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 <br /> G:\FORMS\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />