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MARION COUNTY PUBLIC WORKS <br /> it BUILDING INSPECTION DIVISION <br /> —• `��1�� 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, f S friockey , have authorized <br /> (Property Owner/Print Name) <br /> Josh Hansen ( Oregon Sewer& Drain LLC) 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 /> 1 I ' l Gi �►� �,� 124 sE. cZ act 31�7 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 07,►..k, S G GG t 3Cx.) Tax Lot#(s) t 3 by f 1 ZZ0 <br /> PROPERTY OWNER: <br /> Printed Name: 14 rit♦ cileC key <br /> Signature: Date: k \-3 4 - 2..3 <br /> Address: (j i l.{ec,x E- Phone: <br /> City, State,Zip SAS.? -.-t t GiZ g 3i7 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon Sewer& Drain LC <br /> Signature: Date: r!-2`7— <br /> Address: PO ox 1282 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:\FORMS'SEP71CCS-0"7 Audi to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br /> 1 <br />