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N <br /> /-/ <br /> e <br /> dielf ,,,,,,,,,,, . <br /> ..0: <br /> — <br /> ,........3.......-... .,,...„.--5- . <br /> - --.:-...- -...„...--.5-...-------..1-. -.....-0 <br /> ,• ,. , MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 1.,5.5 Silverton,Rd N.E. <br /> Salem OR 97305 <br /> (503) 88-5147 Fax(503)588-7948 <br /> http://wwwemmariomorius/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> , , OO f <br /> I, AI iLr\t-) Jin 4 ferdaffl e--. . ,have authorized <br /> ' Owner Print Name) <br /> t --- ' r I (1/1014r1— <br /> \1471Z ' ' / . to act as my agent in performing the <br /> (Authbrized Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits, and Other onSite wastewater treatment program <br /> .services provided by the bepartrient of Environmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071., <br /> PROPERTY IDENTIFICATION: <br /> LISO ali.4 SnorlavNiv !Aux-A \KY Gatn , OIL C41 314to. <br /> Property Situs:or Street Address <br /> And described in the records of MARION County as:. <br /> Legal Description . Tax Lot#(s) <br /> PROPERTY OWNER: . <br /> Printe4nle; P\\ ULL);irl ct- 1 Qndt , or MoQ._ <br /> Signature-k e.-_.1e_ Q) <br /> 5 A- <br /> Date <br /> : <br /> 311„ 01Z 4 <br /> Address k) z _l11Ku)L1 uk\ Phone <br /> City,State,Zip L -6( <br /> Fax <br /> E-mail Address Lo-04c)benadco 6 yal I., <br /> AUTHORIZED REPRESENTATIVE:. <br /> •Printed Narne: ----136.2; FLAA:fi ma 0 <br /> Company Name: F...4vit:ooko.4 SNUL- 04 (..0 VI St.4 V1 tt9 <br /> $ignature... Date: 31 16.1.14 <br /> Address:. irro suj Acill, AtI,4_, Phone: Li 5s-11.60-1:ri-si <br /> city,State,Zip a ekta4, O-rt... 4111.1.t Fax: ' , • <br /> E-mail Address tylt.#0..ciAvi4 oliko.c.0 viSalti.11. , c-...c7;;A <br /> DEQLicense-ii- CCB#„ <br /> • <br /> GAFOIIMS\SEPTIOS-OTAutti to Appiplot <br /> NICS,07 Rev,cIS/10 . <br /> SEPTIC 4 <br />