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MARION COUNTY PUBLIC WORKS 0`s <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 MAR 16 2021 <br /> •Sr.4. <br /> http://www.co.marion.or.us/PW/BuildingInspection � IN,Sppr7� <br /> TION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> \\I On \Q have authorized <br /> (Property Owner/Prin ame <br /> t'1r1 A 1� Ol Oh \D P 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 /> I 0 s‘ tY1m mcK I-1(1 c ak_ rn 02 O <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: S\k(Q <br /> p o Cl � Phone: 509,.44-t ' � <br /> Address: 1� 4� �,�s61�1C� 1 \`� ©GZ <br /> City, State, Zip 0,5100-kkz 1-("A 5 \ Fax: <br /> E-mail Address V\rl V10(rie S� cor-WooK•cx)c <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: k t C10‘ (0\\*•.1 Ct �'n 1 J '��c <br /> Company Name: 'T LLC- <br /> Signature: 4Date: <br /> Address: av X \-‘ (7) Phone: r);' T11 Cl <br /> City, State, Zip \gbh G-'r C2 cA1 o Fax: <br /> E-mail Address A\C\h6 or C8 v u.i b �v+�l <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />