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♦ <br /> MARION COUNTY PUBLIC WORKS <br /> ,11 " BUILDING INSPECTION DIVISION <br /> %`���. 5155 Silverton Rd NE RECEIVED <br /> MI <br /> �° Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 JUL 12 2024 <br /> www.co.marion.or.us/PWBuildinelnsuection <br /> i <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I,. a►'tl) el (6 ,have authorized <br /> (Property Owner/Print Name) <br /> I <br /> ( 0ej avv Pj e4'\^1&( ,)& to act as my agent in performing the <br /> /(Authorized Ptepresentative/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 /> Q5 `7 b Ate. SE Sqtkvi c 1.73 3 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Named C v�r7) l_. ( (t� <br /> Signature: Date: 7/( l ZLi <br /> Address: Yi.Si?) p7<' 4-V".,2 5 Phone: -(P-z'2j6-- g 2.S `t <br /> City, State,Zip cti Le.KA 0 it y 7`3 k I Fax: - -- <br /> E-mail Address C 04e I I t w i 2Zc-tvcitS• AO-- <br /> L <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: reo t8 r` C a'T :t'C �;/;a , 0Signature: / _- ti---_ _ Date: 7 c <br /> ri <br /> Address:e7 7-.0 ' 60:t G 7 0 Phone: ,50?�1 88S - 6 a76 <br /> City, State,Zip /4 on 01 .. M c8 Fax: <br /> E-mail Address s.)N,c br c- 4. :i:r ft IZAC e4 61/Aet I.. Cow <br /> DEQ2 - <br /> License# �� I 9 ! CCB# al 7 -3I <br /> G:\FORMS1SEPTIC\App&cation Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />