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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE -c3 ((�� (� (��/'r� <br /> Salem OR 97305 L� L�L v � � I <br /> (503) 588-5147 Fax (503) 588-7948 , <br /> http://www.co.marion.or.us/PW/BuildingInspection DEC 1 c 2023 <br /> MAKIVIv •�:s <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, L Pe. Wyf have authorized <br /> 3kott (Pro et?rty Owner/Print Name) <br /> � to act as my agent in performing the <br /> (Authorized Representatjve/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 /> cl oS -iszk , 44\ ` A, Sk I ci13OC <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 /> PROPERTY OWNER: <br /> Printed Name: <br /> Signature: Date: 12 \1 lcooaS <br /> Address: a(Ci3 TowikAor. At 11 td 5 t Phone:(i2c3 -o2O( <br /> City, State, Zip Sckletk, O . 1180C Fax: <br /> E-mail Address Lee e ocsher , t'OYn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 3kK M058t(A <br /> Company Name: _ her( oc <br /> Signature: Date: al ta5 <br /> Address: ct�g p rj . L QQ �I Phone:C�g4-OH I <br /> City, State, Zip `43q1e0A., olISO G Fax: <br /> E-mail Address "S M (\12,Atc6kerivo,6e. C,Orik <br /> DEQ License # CCB # <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />