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H <br /> MARION COUNTY PUBLIC WORKS <br /> j,'r BUILDING INSPECTION DIVISIONue <br /> 5155 Silverton Rd NE <br /> Salem OR97305 <br /> (503) 588-5147 Fax(503) 588-7948 JUL 16 2024 <br /> http://www.co.marion.or.us/PW/BuildingInspeefion <br /> MARION COUNTY <br /> • BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> / 1 ./ ,, have authorized <br /> (Pro erty O er/Print Name) • <br /> 4,1 1 �r , c vA 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 /> 9 o gc\ Sxiteml_ <br /> • Property Situs or Street Address . • <br /> Described in the records of MARION County as: <br /> Legal Description `CAS 21 Tax Lot#(s) Moo <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: i< <br /> Signature: ei� gd- . Date: -- 1 V z-3 <br /> Address: 1123 .(ajLem pf, ,. 14."- ' Phone: 5- l '-P 7 3 I & <br /> City, State, Zip UiC.v+ti 0 q 73 0 9 -4,r4 Sb1. ce7 Ltvbr <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE:/ <br /> Printed Name: I4 C t✓l 'Z- <br /> Company Name: 14.0� \`t75Ze., E fut.,*cider e, <br /> Signature: Date: 7-14- f ., . <br /> 4 C�c <br /> Address: �(j- .G.4/1a..1)k ct $ Phone: 5:1 ct.s2_ ttrzs• <br /> r- <br /> City, State, Zip ' J,,n q,7 3 Q 7 Fax: 3 t1 f) 6c7b <br /> E-mail Address Cc4 a.°I , <br /> DEQ License# • T 1Z C CCB # /1 T <br /> GAFORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br /> • <br /> I� - <br />