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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Mgt 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 /> I, I ; VAs ie-e z- j ,have authorized <br /> v (Property e'wner Name„ <br /> $eqi. <br /> 4 .y /44 q, me4iii to act as my agent in performing the <br /> (Authorized Repre.sent vel 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 /> 702 d /1) JbiDie ci'7D7 <br /> TvOperty Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot n(s) <br /> PROPERTY OWNER: <br /> k Printed Name: iree..)2• na <br /> Signature: cY\(:).\1: %.:-% ?A \I ( Date: 5 ,3— 2ir <br /> tv Address: k.56) 6 S 71- Phone: 5b3—two-iqy'r <br /> Or City,State,Zip .0...)0,1-)cA Fax: <br /> of E-mail Address .2-,eeé &ljAAL <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 55 j <br /> Company Name: 4(._•ti'et/ nrer <br /> Signature: Date: VOS-ht <br /> Addres . O 6 Phone:5.03 751-- 0,1 <br /> City,,State,zip 5 le 773/7 Fax $ o 3 - 575- 220Y1 <br /> E-mail Address Ce Cl-In fl 3elq1/. corn <br /> DEQ License# . ;1(3Z.3 CCB 50/7/ <br /> GAVORMS1SEPTIOS-07 Auth to Apply.tioe <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />