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MARION COUNTY PUBLIC WORKS C � <br /> let <br /> BUILDING INSPECTION DIVISION -66 <br /> 5155 Silverton Rd NE D �5 �� <br /> Salem OR 97305 r <br /> (503) 588-5147 Fax(503)588-7948 <br /> 01: <br /> www.co.marion.or.us/PW/Buildinjlnspection MAR 1 3 2023 <br /> jV►LDING!NSPECTI' <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, ,& c4vI c7/kc , have authorized <br /> / (Property Owner/Print Name) <br /> !� U-r c ( ailr,e✓- 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 /> /3 0 7C> 1 kr7P1 N g J4tA r C , Z�f 12A' 72 <br /> Property Situs or Street Address <br /> And described in the records/ of MARION County as: <br /> Legal Description d 7 / W I i3 Tax Lot#(s) 0 3 O(7 <br /> PROPERTY OWNER: <br /> Printed Name: Re4441 e ! Aor ��etc <br /> Signature: `G' 1001 / Date: a 3 <br /> Address: ie4,r Phone: Sds ?rr SG 79' <br /> City, State,Zip Oran` O e 97oa Fax: <br /> E-mail Address te-G hSill,/e 016 4-40 01 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /a r V. 1 ' A el +4.0 <br /> n �, <br /> Company Na vet?r Oa v 21 /1') f t,.1 r i-' c 'S I L- e- <br /> 1 <br /> Signatur ��.,,... Date: dZ. - j 3 - Z 2.3 <br /> Address: per' • 57 / Phone:Sat3 -3y7� l� l <br /> City, State,Zip Z.0 l e_ C e k- 0 it "I 7/Z2-Fax: <br /> E-mail Address L A r 0 0, Cots C r,0_C Cc_-p r,1-s' . G Q vv. <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />