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-Z3-oo Z5 PRmT <br /> MARION COUNTY PUBLIC WORKS RE ©L <br /> � BUILDING INSPECTION DIVISION v <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 APR 20 2023 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection MARION COUNTY <br /> BU LDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, E r'i L Do,ii / have authorized <br /> , // (Property O r/Print Name) <br /> /VO/ r7 j z,' -Ff oottit. conbE,wa,'oiJ to act as my agent in performing the <br /> (Authorized Representative/ rint 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 /> 1 93L Sit vac•-iki-a° - �. Sukt i 0 r <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) O i1 E.Z)Oa) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: Er t CL L• CIO% l <br /> Signature: Date: y I/f U) 1.5 <br /> Address: /6 L S Ham'a n5ket R. \ We Phone: <br /> City, State,Zip .tihp Crf-00. r' 1732/ Fax: <br /> E-mail Address P_ra t e_fii�UCr4 tQSGb C -Cosl <br /> AUTHORIZED REPRESENTATIVE:t / <br /> /V Printed Name: O/A gi,.e,n z <br /> Company Name: I ow Li ne Co in S}rµG-l-4O". L LC <br /> Signature: Date: 0002 3 <br /> Address: 11 oS S+n• S+ Phone: 5O3-(17 I-4 3 0 7 <br /> City, State,Zip Sal.e.vv. ®(Z 9 7 31 7 Fax: <br /> E-mail Address Co+vg%-ri.t c-Woe . pr l o t` 0 q r+ ;I .Lo <br /> DEQ License# 3 9 7 4/ CCB# 219 Lt9Z <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />