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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE rc-EmErs) <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> FEB 28 2019 <br /> http://wwvv.co.marion.or.us/PW/Building,Inspeetion MARION tour ttp fY <br /> BUILDING INSP Q t ioN <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, l t,Z.LG , have authorized <br /> (Property Owner. u Print Name) <br /> p <br /> 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 /> 52aS 1..0665 Rd NE C.) v-Uc,.,s cp <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 214°1\tA Tax Lot#(s) v52w 2 a 0 03 a v <br /> PROPERTY OWNER: <br /> Printed Name: / .�f//2/c,f� <br /> �r G Date: -/ `�'�� <br /> Signature: JC �� ,� / f <br /> Address: �� Z i/J ,& Phone: J�.�— 97Yj/g` <br /> City, State, Zip 1/4�� G4 1 76 Fax: <br /> E-mail Address PG-u°`-c,C'e7/0 c./77 - . (: <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: `i) i v ‘ , V ep< <br /> Company Narn : r,,,,� 1..c e L -1, -Q l�t,.f .g.snju-ite- <br /> ,� Date: 7/ <br /> Signature: /.�)/,�� /•--/f <br /> Address: / 9' l Y g ice- 41A) Phone: S 0� 9/4 `/14 <br /> City, State, Zip 511*LZ v \ ) 36 y Fax: • <br /> E-mail Address C O V 1J li U' S ) i41 5!-I ' 6P '1- <br /> DEQ License# CCB# <br /> G:IFORMSISEPTIC1S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />