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ad'I' ► ..4'nnitit. MARIVIV COUNTY YU,KLIC WV �2 C <br /> E III V E ---: <br /> `�' BUILDING INSPECTION DTVISIO V <br /> �.��'����; S1'Sfi Silverton,Rd NE I <br /> Mil <br /> .- salem O 97305 AUG 15 2023 <br /> (503)588-5147 Fax(503)°588-7`948 <br /> htfp.//www co.manoa.or..us/PW/13nildin l'n1 trill � COUNTY <br /> �.� trill <br /> I SPEC7`ION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, CACA1' r ,have authoriz <br /> (Property Owner/Print Name) <br /> ar p -Scab c.S to act as my agent in perfomM <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits,and other onsite wastewater treatment p <br /> services provided by the Department of Environmental Quality or County Agent on the proper <br /> described below in accordance with OAR chapter 340,division 071. <br /> ' PROPERTY IDENTIFICATION: <br /> 1 cc 5 4-i AAA._ QPLA;t o< `1 SLt 7. <br /> Property Situs'or.Street Address <br /> . <br /> And described in the records of MARION:County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> . <br /> Printed Name Cre t3 r�e� <br /> Signature Date: L./Jr/7 -s__ <br /> Address: t)LS't'( 5 �1;� Phone: <br /> City, State,Zip e.t... / 0 e_ c779 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ,jam•&Idol tNL• t.. 1 <br /> Company Name: ^'Gtl <br /> Signature: Date: .(,t,/8/23 <br /> Addre .F).. [30,e I "lO t Phone: <br /> City, State,Zip t,-- i Its_ 04. 411 37 g- Fax: <br /> E-mail Address w ,1.(tit..., <br /> DEQ License# ct.S(,i CCB# -I-,22,61. <br />