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�I` ,,�1��,, MARION COUNTY PUBLIC WORKS <br /> +++ BUILDING INSPECTION DIVISION <br /> _%�� �. 5155 Silverton Rd NE C������ `m I <br /> Salem OR 97305 RECEIVED <br /> IMII (503)588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection MAY 0 3 2024 <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> )�� <br /> I, i f t_ ii 9 i-- , have authorized <br /> (Property Owner/Print Name) <br /> 1\C-t I- -v \AI ZICI-N. 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. <br /> PROPERTY IDENTIFICATION: <br /> 0q5- Offritg (Pc-4 6 :SG - ole- q)3/7 <br /> Property Situs or.Street Address <br /> And described in the records of MARION County as: <br /> Legal Description C(y5 kr`f ig e re.,, cg Tax Lot#(s) R5 3 WIZ q boo / co <br /> PROPERTY OWNER: <br /> Printed Name: ,� . 6'��1 (YJ <br /> Signature: Jy;;, . Z...a4*/ Date: / 1011 ZdZ <br /> Address: 095 /i tE , e4 . Phone: 5 j'35 " 728? <br /> City, State,Zip ifrei 0. 9 7c/, Fax: 51)7 5e,5---4 7— <br /> E-mail Address itt a " (i ti 0 Coil cads,—oe <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: J<'/I t✓;r'' Viklitk <br /> Company Name:A/(ice L.,nt Om 0-ti.tA e ►C`n <br /> Signature: ' ;-,;f .r d' _,yam") Date: 5 /).2 a 14 <br />