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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://www.eo.marion.or.us/PW/Buildinginspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, <br /> e--"t_ te-e_ 64)-e,A6,A ,have authorized <br /> ,(Property Owner I Print Name) <br /> 6,4 \ ova- tilei;FiD1 4;1-46- to act as my agent in performing the <br /> (Authorized Representative I 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 /> / Y Cril)9/Wet/ //74),741 C2 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 1;1(1Am:fel C14 ,616., Tax Lot#(s) 7 <br /> PROPERTY OWNER: <br /> Printed Name: --LA9c,-)c_ Latce" /A-k-- <br /> Signature: e Date: <br /> Address: -2r"-i/:alie- 1.4 5 67. Phone: So-3-5'0/-3'5 <br /> City, State,Zip 7E4 r-ri 7 3 9 2.. Fax: <br /> E-mail Address 3 pa-el) e„ epla- Ia Coes-) <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 14 tAll, tuCZL 7/5/k-17' 6a r-ci <br /> Company Name: <br /> Signature: /7— Date: 7 If zcz <br /> Address: Vb Z-14 laXiate7t.tAK. C`i Phone: 9)3 QSZ. °I-404 <br /> City, State, Zip ,/(,(ikt. 9 75/ Fax: <br /> E-mail Address tAfrOke,xect....ateirc7elglet t7),C 00,1- <br /> DEQ License# 3i23 CCB # MST <br /> G:\FORMS\SEPTc\S-O7 Auth to Apply doe <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />