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I <br /> ,;. .,,,;�;j IVIARION COUNTY PUBLIC WORKS <br /> D C 1! <br /> ,'' BUILDING INSPECTION DIVISION <br /> -1���= 555 Court St.NE Room 2260/PO Box 14500 - DEC 18 2020 <br /> --- -, Salem OR 97309-5036 = C( <br /> e ti'e (503) 588-5147 Fax(503) 588-7948 MARION COUNTY <br /> `� '. .-� 3UILDING INSPECTION <br /> .:-, http:/Jpnblic�orks.co.marion.or.us/buildang/ <br /> a 2C6-06 9 i9s <br /> NOTICE AUTHORIZMIC REPRESENTATIVE <br /> I, D ,e, _ b,Ji Se have authorized <br /> (Property Owner/Print Name) - <br /> Lo v )N,N:� 5 th-1-1'c-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. I agree that any costs not satisfied <br /> by the Authorized Representative are my responsibility. <br /> PROPERTY IDENTIFICATION: <br /> 12 3 s 6,rb t ;,L -,j f-- G)1 <br /> Property Situs or Street Address __ <br /> And described in the records of MARION County as: <br /> Legal Description - Tax Lot#(s) / %670 <br /> PROPERTY OAR: , f <br /> Printed Name: 0 \,� v) s - <br /> Signature: ,0-'V: /fit/k-- Date: I z..- t►- 20 <br /> Address: [23 F /73=10 1 sill—vim Phone: ?i 11 - A-) Lr--r--94,47_5 <br /> City,State,Zip . 6,-c ,s v r 4 /3 �I Ca Fax:E-mail - <br /> Address . <br /> AUTHORIZED�jREPRESENk`AT VE: - <br /> Printed Name: fie rtx y (. t150 tn. i <br /> Company Name: i-ori.t Pant_ Corr S11.?k-.c-� �Nc,. <br /> Signature: (1 W IA.Y15V\ Date: 15.-A\`11),as <br /> Address: co 1-4%, Cascia. MAN .A/c Phone:503-9)1- - . <br /> City,State,Zip St 1v4!.rkop,b OZ. 1 61.1--SV, Fax: 5 b -S1.3755'CPA- . <br /> E-mail Address E 4�,,,,, i41 e �jtn� <br /> DEQ License# 00 CCB# j CaC@` <br /> S-07 Rev 03/05 <br /> 0 <br />