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. .11-&, ,,,,,- - ., . _ ‘ MARION COUNTY TUBLIC WORKS
<br /> 14,4%,..T.
<br /> -..-- ,-2,111111,, z. gUIEUDINd INSPECTION DIVISION -1ECEVE, 5
<br /> 5155 Silvertbn fld NE
<br /> •••.,....--7-----7:---,---..-•%,..---------v
<br /> , _'';2':.• . Salem OR 97305 ' - -I APR 1 0 20:3 Id
<br /> (503)588-5147 Fax(503)588-7948
<br /> 1 Z:.•,--, ;:--.':'-',...7F;;;i,A, http://www.comarion.or.us/PW/BuildingInspection IVIARION COUNTY
<br /> BUILDING INSPECTION
<br /> •
<br /> • Ai NOTICE AUTI-101P I,ZING RP lk i SENTATIVE
<br /> 1 k,t ar 4 i -ichti ,have authorized
<br /> 2
<br /> (Property Owner/Print Name) • ; •
<br /> Katie Ryan . . . . 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 'ILENTIFICATION: ..
<br /> Property Otus or e t ress
<br /> And described in the records of MARION County as:
<br /> Legal Description Tax Lot it(s)_
<br /> . _ i
<br /> PROPERTY OWNER:
<br /> ,
<br /> 0)(1(ine
<br /> Printed Name: iC\ ovitirk t_ , , ____ „ _ _ _ 141 1 -tAbi, /
<br /> Signature: '.( (a—e-; iftc Le---a-ei i i (- Iv‘IjIr-A'Q-12--•ri A It_ _Date:
<br /> 7 0/ 6D -- q o- 7YYZ
<br /> Address: i, L__4, (p • biAl Crdic Y Li( Phone . . 3 -
<br /> City,State,Zip 1 U lit,h1A-- )1L- Co-591. Fax:
<br /> E-mail Address r trn...1-VCIrke_A.I. 12,Zn ( ) 5 .ma 1 is csy 71,-,
<br /> dAtkif,,z_vy, 0,0,-,,,Av -761. te e shAcc2(,e3(1/11
<br /> AUT °RIM REPRESENTATIVE:
<br /> Printed Name: •Katie Ryan
<br /> Oompany ;e: . thel Re6austing
<br /> Signature (.AA _ Date 1-1-I D- 23 •
<br /> • Address: PO BoX 504 Phone: 5ns-743-9143
<br /> City,State,Zip _ Turnpr, OR 9P;c12 Fax 501_7.3. 638
<br /> E-mail Addiess_office@beth'elelexorri
<br /> DEQ LiCense# 35195 CCB# 44554
<br /> GAFORMSISEPTICLS•07 Auth to Apply.doc
<br /> wipsig Rev 03110
<br /> SEPTIC 4
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