Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> iv • BUILDING INSPECTION DIVISION <br /> — _ <br /> 5155 Silverton Rd NE <br /> m Salem OR973.05 <br /> (50)588;-5147 Fax(503)-588.-7948 <br /> http:thirww:eo:marionxr.us/PW/BuildingInspection <br /> . . , <br /> NOTICE AL/II-PRIMO REPRESENTATIVE. <br /> A <br /> L AI Vkni.zin. ct B(QiNciaMoo( e- ,have authorized <br /> ropety Owner/Print Name) <br /> , ,, II( iy\OL.n to act as my agent in performing the <br /> (Atnlib.rized Representative/Print Name) <br /> activities necessary to obtainsite.eValtiatioris,permits,and other onsite wastewater treatment program <br /> .services provided by the Department of Environmental Ouplity or CO-Linty Agent on the property <br /> described below.in accordance with OAR chapter 340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> LISO .614 &a,Atio.A. .VA‘1.31/4.% \.0 OrIL Crl <br /> Property Situs or Street Address <br /> And-described in the retords of MARION county as: <br /> Legal Description Tax Lot li(s). <br /> PROPERTY OWNER: .. <br /> Printed Name; A\ Ut.,t):1 I) 6 4-• : .. 0 r Q_01yin' Mo <br /> -Signatutetl L Date 31 i 2/24, <br /> GI\Address.. 44 1/4, t....). • . 0.:( Icl , 41,0 LA 10 Phone: <br /> ? l' <br /> ntL, ,111 i <br /> City State,Zip '0a-VeS i oe 1. --t- C--1 10 Fax <br /> E-mail Address befl&ice 6 Ofkai . , e" ON <br /> AUTHORIZED REPRESENTATIVE:. <br /> ,PrintedNanie: —174k.tt RA.6 VAG N <br /> Company Name: FI,Inil%mob% S.044_ 0.c.. ..i t Cot,SLAVi N5 <br /> Sjgn4tIkt: ',' L ± 4-.--- Date: 31#6 1-7;d.4 <br /> Address: co et.-1 svd A 003- A kui Phone: Li 55-'IUD-Intl <br /> City,.State, Zip Po rtto4, Ô . c11:1-1-Vt Fax: ' . <br /> Errnail Address tyle.4,0-2tAvi%vv,g3K Go vts‘A U,,A,1 . c-0;g" <br /> DEQ:License-# CCB# <br /> GilOORM§XSEPTIOS-OTAtttli to iypiy.drk <br /> mos-a7 Rev.:03/1 0- , <br /> SEPTIC 4 <br />