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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://wwvv.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, py c4 �( �,a I t S have authorized <br /> I (P ry War per t Name) <br /> �,e(��yy „ j to act as my agent in performing the <br /> (Authorize(d Representative/Print e) <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 /> 3CJ C1 J,e- PeR50,u —Se.; 1`)2 _S L ,.�� .,�� �� ck <br /> Property Situs or Street Address 7 73 5 2 <br /> Described in the records of MARION County as: <br /> Legal Description )O3 vv l.3 Tax Lot#(s) Cl^ <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: t^ ' <br /> Printed Name: KA R E N I V E LLS <br /> � <br /> � am <br /> Signature: �'1 �� - 3��--5 Date: _ 3 I-A 2 0 2Z <br /> Address: 30 66 -3-.��Cacsor Sc- o Dr S Phone: 5 03 1 C)' 2-.3 Z°` <br /> City, State, Zip so.1\ O \ (: 3 5Z Fax: <br /> E-mail Address W \\S ri-\0 sod' 30 C5) Oy\i\cam \; Cpw\ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: jTeferz.i <br /> Company N : /-J J 6c �iej c it J.0 • .J-)C. <br /> Signature: Date: <br /> Address: / en,c_ Phone: 1`�l�'7`l�.2�rS <br /> City, State, Zip eAJDAJ C �Z? Fax: � <br /> E-mail Address ( ,T"J cy� OU`--/x< . �.M 1 <br /> DEQ License# _?97 7 CCB #0213 77 62 <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />