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OL1 t5bn <br /> REGENEIL <br /> JUL 30 2024 <br /> 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 /> litip:Av*M.coanarlon.or.usiPW/BuildhigInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> L tika,t E. 57I E t ssi--e 5Yet(e_ 19:41,i0 cfretA4-7nest have authorized <br /> Tv. rop cdtty Owner 1 Gil_Tin Namejv <br /> : P 04$4.1f , a*/ (441 to act as ray agent in performing the <br /> (Authorized Represen • Ve Print ante) <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 /> /5.-20 core,ti: ? 73/ 7 <br /> Property Sittig or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: (A 11 Srg E 53-ee k 4-ettyt 't 34,fht ve tru,5 el/424 <br /> kSignature: _ S 6',/, Date: 6/1tg7/0 .4( <br /> r Address:, ,2`i 9 rre-vi Phone: 96 j 7 44 <br /> city,State,Zip rak c-;etA F 31175- Fax: 1' <br /> (Ir E-mail Address tirk Alt dive 5-7J-5-15-L(• g I. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: j -C. $5 Z_ 544744/.j <br /> Company Name: /1 .-t;t74,7, Vrq <br /> , <br /> Signature; Date: <br /> Addres5. 737-17,54itt; Phone:503— (7'432.---,z4,€)) <br /> City,State,Zip S.rittew). 773./.7 Fax: cei 3 - CeP5- <br /> • <br /> E-mail Address c4. l'haklirq;#1,005 04 I 1. C011/ <br /> DEQ License# 34t3z3 . CB 50/7/ <br /> GAFORMS\SEPTICNS-01 Auth to Aftlity.doc <br /> Aka.1.1 <br />