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IVIAMON COUNTY PUBLIC WORKS d5-T5b 835_D-- <br />, <br /> ..11: <br /> BUILDING INspEcnoN DIVISION <br /> siss Sdverton Rd NE ---9 = C Fq V/ m' <br /> i__,, _._ <br /> Salem OR 97305 n <br /> (503):$88-5141 Fax.(563)580-7948 - - OCT 0.4 2023 <br /> http://www.Co.marion.onns/PW/BuildingInspection <br /> UN COUNTY <br /> 1.3UILDING INSPECTION <br /> NOTICE AUTHORIZING'REPRESENTATIVE <br /> 7 1, c,c- 7 a. ,..1„.„..)-e, (( <br /> ,have authorized <br /> roperty Owner/Print Name) <br /> t•-• ,t,A.) k csr- 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 ofEnvironmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340,division'071., <br /> PROPERTY•IDENTIFICATION: <br /> Property Situs or Street Address <br /> And described in:the records Of MARION County as: <br /> 3 3 0_ _74 id....— ry-- <br /> Legal DesctiPtion - —'e-e— Tax Lot#(s) <br /> _PROPERTY OWNER*-.. <br /> Printed Name: Z ep*.t. -e Zee ie -c-,4-."-f--(( <br /> Signature: <br /> Date: <br /> Address: ,. 7-6 6/ 6itej7,6.31, ‘eve- J47 Phone: , . J-ZE ) -?,- .6(k f- <br /> ....„"."7 <br /> City, State,Zip ea,40-4 C.)A 76).6 FOX: • <br /> Email Address r„,.......,c.-. , cd-1-7t. <br /> AUTRORIiED REPRESENTATIVE: <br /> -..__,________________... <br /> Printed Name: I t e- <br /> Ciampany Name; O .,),e vA, ieN.. 1-•r '• ' <br /> _ <br /> Signature: <br /> Date: <br /> Address: Re . t t•, - . Phone:.. .City;State,.zip / . 1-- ,kf_..c___ 6(7 Fax: <br /> E-mail Address . -T- c,i .: ' . r C__. <br /> DEQ License# ;____S___ a CCB# /e— 6.______ ____________ <br /> 6:SFORMSISEPTIC‘S-07 Auth talipply.cloc <br /> IVICS-07 Rev 03/10 <br /> SEPTIC <br /> 4 <br /> ____ <br />