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MARION COUNTY PUBLIC WORKS <br /> '"'. BUILDING INSPECTION DIVISION <br /> il� 5155 Silverton Rd NE <br /> � . � Salem OR 97305 <br /> aii (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildinglnsuection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Mari C7/4c ,have authorized <br /> d (Property Owner/Print Name) <br /> A a r v-��ff C( a v, zi 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 /> 0 0'70 Z I 1 e1,1 P Al 5 lq LA r ae.o► / m �l 2 2 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 0411 / Vii /LLe Tax Lot#(s) 00 3 00 <br /> PROPERTY OWNER: <br /> Printed Name: QC44'1 e / fixer �/ec <br /> Signature: •:04 Date: 2/a a 3 <br /> Address: i0f0! 4-. ?V/ Phone: 5.0s -xfr- Sa 7p <br /> City,State,Zip 4r€cti 0/ 97oa 2 Fax: <br /> E-mail Address G hs'b»i oe on o G.Go$1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ZEit r v LI n IF /1 J✓' <br /> Company N Pr 0 f0?r2 Oa v ei1 inek� t rV1eae c I L �--. <br /> Signatur Date: 02.— /3- Z f?2-3 <br /> Address: P.0 6o-y 57 / Phone:5:0 j '397— lI 41 <br /> City, State,Zip E i e_ Cr -e e k% Q X- 9 7pZZ ax: <br /> E-mail Address L0.rr1 0 ( GAsCaC)o-ctC.c_e S . CO vv <br /> DEQ License# CCB # <br /> G:IFORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />