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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://wvvw.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, jt ateLeAl eirl6 /l e—ba e._ Pross have authorized <br /> g.ze:Ter/Print Name) <br /> C (jYl 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: 973qZ <br /> ie le S-700.)-0A <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> PrintedName: � C � l'Il-t/rn I�l l �� a P/1u <br /> go-31-e <br /> Signature: ate: C2 ,Z <br /> Address:? __ Phone: 517/ a-7 3 <br /> City, State, Zip --rug AM L Fax: <br /> E-mail Address c//a/1 41/ f , // 7 cyma, 7 /. CCU <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: <br /> Signature: Date: <br /> Address: Phone: <br /> City, State, Zip Fax: <br /> E-mail Address <br /> DEQ License# ',2j 6 5 091-\ CCB# <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />