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6 ,, MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION JUL g 0 2021 <br /> �j`�� �� 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503) 588-5147 Fax(503) 588-7948 BUILDING INSPECTION <br /> http:/iwww.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> have authorized <br /> (PropertyOwner/Print Name) <br /> to act as myagent in performingthe <br /> �j"�� �r���/r/ g <br /> (Authorized Representative/Print Name) <br /> activities necessaryto 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 /> .3q q7 //O/IT& MIX RD <br /> Property Situs or Street Address <br /> • <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) c8Wt2/ 00/00 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: ,_5:� � 1 ���(�S r / <br /> Printed Name: „� /�P tGy �� <br /> J(P-C /' a. k.t <br /> Signature:c /46' g'e.);;Atee.i,,¢ Date: T' 30 -2 ] <br /> Address: c?O ? KO Z49 .Z Phone: CO3 q53 - 5I 74( <br /> City, State, Zip 7v® -44/0 0T( 9 72/2 Fax: <br /> E-mail Address R,S'PH/CL f (2 695ycrie <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: B/ 4-D g 76:-// <br /> Company Name: E'G/lf762�/" C0gPORA%/0/V <br /> Signature: — Date: 7-39-Z/ <br /> Address: /2303P///Eyll,E$7 k,�y �i�' Phone: 20,`979-/90-7 <br /> City, State, Zip l%-.� 44.1 '/25- Fax: <br /> E-mail Address ,F DE072 2 G'2 E'�/U C/89/.v CO'"? <br /> DEQ License# • CCB # <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />