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MARION COUNTY PUBLIC WORKS <br /> '14 ""� BUILDING INSPECTION DIVISION <br /> =il��`�� 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> MARION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, - ///mil )<L14 ,have authorized <br /> i property Owner/Print Name) <br /> � I i 5 j)Al IAA C y , 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:_ <br /> 110 M a c C4 9��rty rot� <br /> U Property Situs or Street Address <br /> P <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> KK,,f K irwtxx41 <br /> Printed Name: �1,� � /.�-��l GvJ <br /> Signature: Date: //2S 2, <br /> Address: /%7'5-4 o/Y s g Phone: SGj ' /O 7/37 <br /> City, State,Zip Alxvoia. ©F- ?7002 Fax: <br /> E-mail Address 7/ a o f ati e 3 G/ COA-i <br /> AUTHORIZED REPRESE ATIVE: <br /> Printed Name: Ay,-,6) kJ/ Ltd <br /> Company Name: / 4---c i i c MiI C Fec LLB i / <br /> Signature: / Date: G �,(� <br /> Si— <br /> Address: S0 ,y( 6 6 , Phone:Sam"?2 Z 7 <br /> City, State,Zip L A li !Suvl Li E/l e , V 9 70 7CG Fax: Sa 3�7P ,2 <br /> E-mail Address A 6 z c , �1 , a, ia1i GU/! <br /> DEQ License# a �C CCB# /r /i/g <br /> G:\FORMSVSEPTIC\S-07 Audi to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />