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OLI-- 6b1-11-kci8 <br /> , .._ <br /> ` . E .:•.Eiv . <br /> . JUN <br /> „ ,,, VBIAi ttIp co5ligIlt Y[i,$li# W{nois . <br /> I `; - ,di : , +. U LDINISPTIONDIVISOt <br /> N <br /> 515 SiIverton Ra NEI i <br /> € Salem'OR 97305 <br /> (503)588-5147 Fay(503);58-8-1948 <br /> http;%/ww• w co.m .o arionr ns/P'WfBuildingiiispecti"oa <br /> - .. <br /> NOTICE AUTHORIZING REPRESENTA:TTVE ' <br /> {prpr • ,have anthoria <br /> o Owner/Print Name)'r '�...1.c_ to ac <br /> t as mY agent in'.p onmr <br /> (Authorized Representative./Print Name): .. : . . <br /> 1:- ;'... acti�vities-.necessary to obtainsite evaluat on,,:permits,and other onsite wastewatertreatment:p <br /> so , -6es:provided by the,Department efgnyironmental Quality or County Agent on the proper <br /> described.below in aeco=dance"wvith OAR chapter 340,division 071. <br /> PROPERTY-IDENTIFICATION ,- <br /> '6 S flQ t-. Aes a73�(- ,, <br /> ' <br /> . Property Sites•`or Street Address- " <br /> 48 An_d described in the records of MARION County as: <br /> , <br /> Legal 12:0:`ril,tign <br /> . Tax Lot;#(s). <br /> ,, .',..,.:-'.:...H,,,,,1 i . . <br /> .1. PROPERTY OWNER:;.. . .,.: <br /> PrintedName_( s s1 <br /> Signature: `f F• • Date l Z_ cZ ? l <br /> • Address: 1 fib - . f.'; .4 _ one 23)851,.=' OM z <br /> . Ph <br /> :City,.State,Zip..;ii�e .. • �QZ - Fax <br /> . <br /> Fa. <br /> E-rnanl Address <br /> lit <br /> RTZED REPRESENTATIVE: <br /> AUTHO <br /> Punted Name: JQ.ncrA 1/�4oioa . <br /> J <br /> Corririany Name <br /> Date: 1 <br /> Signa e: `--- Z 1"Q1 3 . <br /> F Addres -r : lox 4,0 C Phon <br /> 4 <br /> $ •. 1 .. City,State,.,Zip _._ttz: 132' Fax <br /> E-mail Address t,,znt 1, CO t. --t. <br /> ,{ DEQ License I/ . q,.b j CCB# b -77 <br /> u6o,aca««a.0�k 2 • t• .Mt-o.., <br />