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�����,, MARION COUNTY PUBLIC WORKS <br /> 'III ���� 17 BUILDING INSPECTION DIVISION <br /> --►1 5155 Silverton Rd NE <br /> Mg Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> II <br /> 1, ��L U 1 e4A L. Le. ._ WZ"-.&A , have authorized <br /> __(Property Owner I Print Name) <br /> '.<,✓t. \ vvZe- L kjsuc,v1 ; u.. to act as my agent in performing the <br /> (Authorized Representative I 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 /> MW Cat <br /> / Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description friclAvitt 1 C.1( 1L. Tax Lot#(s) <br /> PROPERTY OWNER: J <br /> Printed Name: — (A9cn L + Laity, IA) - U <br /> Signature: // ` Date: 7/o1 ! /22. <br /> Address: g v l & .SLC- Phone: So3-80/-35'3S <br /> < <br /> City, State, Zipu /' D 7 3 9 2 Fax: — <br /> � le 1� <br /> E-mail Address 3 r )-e�b /-i O l-t e, C�, "a_</, co f-) <br /> AUTHORIZED REPRESENTATIVE: // 6ar-elw <br /> Printed Name: �ti C / )/'1 ✓ pr <br /> Company Name: Lv1, t;6?--L- F t\,)64'(,01/I :1 C <br /> Signature: / Date: %f lf z-U1 Z- <br /> Address: i L t(%tt.J14. ci Phone: .} Q C)110-1 <br /> City, State, Zip Si/60 . CA c 73/ 7 Fax: 51)3 3 65S 30 <br /> E-mail Address tAt,OkL..x,e c.ax.-1-dv''' t.v),C U6'"t- <br /> DEQ License# 5 2 3 1 CCB # A4S Y CZ <br /> G:\FORMS\SEPTIC\s-o7 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />