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MARION COUNTY PLJBL1C WORKS IV D <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> ` ' Salem OR 97305 APR 17 2024 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1- f1/V —hots( (20,-se 7 3'03 - / --- f g3 3 . have authorized <br /> (Property Owner/Print Name) <br /> r. rr y /ve Clean S/c-J 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 /> %, )1/10474 /7Lr,l 11 l �.s D2 `f.73`-f L� <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Fk 2 Ln4 I Tax Lot#(s) d 4 o I'e7O <br /> K z VAC. 5`j' <br /> PROPERTY OWNER: <br /> Printed Name: :> i3�7 ,; tr 11 <br /> Signature: /'j/LJ_4--c'-? - Date: "�j -� <br /> Address: ?.p4 -e-►r, ((Pf` - - _ Phone: C.S- 03 <br /> City,State,Zip W\\ C (/,,,O Fax: <br /> E-mail Address C C/{5(:)i1<C--j;;,r (63 U(O <br /> ) <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: %e. e - /Ue 1-64 <br /> Company Name: Cie r-i/t S LLC <br /> Signature: 77,7 Date: 3-5-, <br /> Address: 5�f�0 J/.dp, - r LJ x Phone: 563-- 9 3 - <br /> City,State.Zip ,S'c..J i,i rt 7 3 C Fax: <br /> E-mail Address L/ s/ y -h ec - <br /> DEQ License# 3q(`i 0 CCB# rT (`-'7 <br /> G:IFURMS'SEPTIc'S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />