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MARION COUNTY PUBLIC WORKS <br /> ,flAtili;„:,s,;!.. BUILDING INSPECTION DIVISION <br /> �_i1 5155 Silverton Rd NE <br /> iimi Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection /U ,-S. q— (2 (— 1 <br /> Z,0 Q D <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, Bra den Le G ra rv,s ,have authorized <br /> (Property Owner/Print Name) <br /> M a({I1ic W Cdwar 6 s 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\1e2,q ot)11u Lvi, lroc, oiz &I-125g <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed NameeG -C e: Bro \ \-Cc, Farri,, <br /> F Signature: ari(A,O * Date: I O-2P 2G20 <br /> Address: 11 I gt-{ 6()r c,- Phone: 503-,Par-f SOU <br /> City,State,Zip 1-'i) S, 0 reun, GI735 Fax: <br /> E-mail Address -Farr.,S. Ixa.c!•.n.1 0)rvl at 1,corn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 7t%t1. te. 2I t--GQk:(.0C(`L --- <br /> Company N e: ti is 3 Si q ik it lrai Z��a)..0 Ctl'Z ---l�C- <br /> ,_ "��._._.... / S.,g/ 7 <br /> Signature: L "� Date: I u <br /> Address: r -C —0 2 — 72_7 Phone:(5.C 3 %7(..--‘i C(C 9 <br /> City,State,Zip LIQyt S q73S% Fax: <br /> E-mail Address t\kt k(4-4 S 0 _uJ VI t , CO 74 <br /> DEQ License# CCB# / 6 ,39''-i <br /> G:IFORMS1SEPI'ICS-07 Auth to Apply.doc <br /> MCS O7 Rev 03/10 <br /> SEPTIC 4 <br />