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hi .1 ,C {1%91 <br /> MAY 19 2023 <br /> 1MARION COUNTY <br /> BUILDING INSPECTION <br /> MARION COUNTY PUBLIC WORKS= <br /> !" BUILDING INSPECTIONDIVISION <br /> ��%� " 5155 Merton Rd NE. <br /> OR 97305 <br /> ... . ...Salem. <br /> 5147 Fax(503)588-7948: <br /> http://www.atunarion.pran/PW/BuildingInspection <br /> �/! NOTICE AUTHORIZING REPRESENTATIVE <br /> I, A C(.6.0--- ;S Cock w, y, <br /> ,have authorized <br /> pre <br /> • PertY OWner•!"PriatlVame) <br /> t ( a\flLe- to act asm <br /> (Authorized Representative"/Prim Name) Y agent:in performing the <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 /> descriibed.below in.accordance with OAR chapter:340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> (I / 'A51,14 1 i—, 5e <br /> Property Sims or Street Address <br /> And described..in the records of MARION County as: <br /> Legal.Description Tax Lot <br /> PROPERTYOWNER <br /> Printed Name •eau/Ina v\ <br /> Signature: Yvt Ad-tyvv),1 Date: <br /> Address: 14i 5.3 .je rr .. , Dr • Phone: <br /> City,State,ZiP Se,t a IAA (' 9 i 3G?2 Fax: <br /> • <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: . T're (Ai Col Y e r: <br /> Company Name: <br /> Qwe rA. 0_35.tnS)-ro <br /> Signature: — <br /> Date: <br /> °xi <br /> Address: <br /> X t I' TO phone: So3 q,e9 /B?4, <br /> city,State,Zip kei' r r D r 97367 Fax:. <br /> E-mail Address retti. C'C t;Vet:L ,VA fc9C tbvtt:v,.C_ c va-1. <br /> DEQ License;# , Z[ CCB ii <br /> cAroRmsts EPf7G15:07Auth.to'APD IY.dar <br /> ... <br /> MCS;l17Rev03/10 <br /> SEPTIC <br /> 4 <br />