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• <br /> MARION COUNTY'PUBLIC W ORKS; <br /> BiIILDIl+IG,1lVSPE£TIOIDMSION. <br /> � g• 5155 S lverton'Rd;NE <br /> S81emOR 97305 <br /> (503)588-5147` Fax(503)588.7948 <br /> s 6 <br /> http:/Iwrvw co.marion:a uslPWtBuildinglaspectiaa • <br /> ;'NO EOTIC AUTHORIZING REPRESENTATIVE <br /> i, � Ct ,have autfigrized . <br /> :(Pr opty:Owner/Print•Name) <br /> Tyler Fuhriman <br /> . my agentmperformiigah e <br /> (Authorized Representative./Print_Narne) <br /> activities necessary,to;obtain site evaluations.permits and other onsite.wastewater treatment program <br /> services provida.by the Depatitment=of Environmental Quality or County Agent on the'property <br /> described below m accordance:with 0Ait chapter'340,.division <br /> PROPERTY IDENTIFICATION: _ <br /> fe> ,titc clepl L*7. t fUt <br /> ------------ TProperty Situs or Street::Address. <br /> And described in:the,records of MARION County.as: <br /> I:egal•itocnption. <br /> ' Tax:Iot#(s)105E01 DC03000 <br /> PROPERTY OWNER: <br /> Printed Name: / ,";>c.t• (FrY f <br /> - Date• 113 _ <br /> Address. `(.7.5 6i ,h fv. <br /> City> P'State,zi rrx�c\ C�%t <br /> � <br /> E-mail Address �m€T`7C ' ,..4at tet n4'. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Tyler Fuhriman <br /> `Company'Name: Fuhriman__Septic Design &Consulting. <br /> 'Signature:; 1`trx - ^"^'"— Date: 2/5/2024 <br /> Address: 8727 SW 19th Ave Phone: 435-760-0717 <br /> City.State,Zip Portland, OR 97219 Fax; <br /> t-inailAddress tylerc fuhrimanconsulting.com <br /> 'DEQ.Licenseat' EH-W-10199358 CGBt/. <br /> 0.IFORMS srres..;Auth lb Apply Vac ... <br /> MCS-07Rev;03b10: <br /> SEPIIG 4 <br />