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MARION COUNTY PUBLIC WORKS a3 -1l ICJ <br /> BUILDING INSPECTION DIVISION -l� r-' <br /> 5155 Silverton Rd NE L`- `! 'J �'= <br /> Salem OR 47305 ij <br /> 3 � <br /> (503) 588-5147 Fax (503)588-7948 NOV 2023 — <br /> http://www.co.marion.or.us/PWfBuildingInspectooa,- ,:1 N U U ] Y <br /> r3UlLUING INSPECTION <br /> fy , NOTICE AUTHORIZING REPRESENTATIVE <br /> I, U Ilv , have authorized <br /> (Property <br /> Print <br /> Josh Hansen � Ore9nSewer &Owner <br /> LL ) 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 /> Property Sims or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description O cC 3 w cj 6 C oOC So' Tax Lot #(s) 300 <br /> PROPERTY OWNER: '�► <br /> Printed Name: 1A.5-1:,v1. 1i• 1 <br /> Signature: Date: I ( P P.o / <br /> Address: , gifibtr c e.• to) 5. Phone: ©3- `qC Z53 3 <br /> City, State,Zip Set kit o - ''1e 2 Fax: <br /> E-mail Address Si‘i > tk t},t kt 40L. CO 3"4 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon wer rain LLC <br /> LL, <br /> Signature: Gi'' Date: i( <br /> Address: PO Bo 282 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•s,�FORMS$SEPT1CS-07 Auth to Apply.iioc <br /> MCS-07 Rev 03/t0 <br /> SEPTIC 4 <br />