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• <br /> MARION COUNTY PUBLIC WORKS �t <br /> BUILDING INSPECTION DIVISION } <br /> 5155 Silverton Rd NE f� ���' <br /> Salem OR 97305EC <br /> (503)588-5147 Fax(503)588-7948 <br /> http://vvvvw.co.marion.onus/PW/BuildingInspection MAR 0 3,,• <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> jPro erty Owner/Print Name) ,have authorized <br /> 7 to act as my agent in performing the <br /> kAuthorized 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 /> 7 yi <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description . <br /> Tax Lot#E(s) 1O EOZDAO 3 <br /> PROPERTY OWNER: <br /> Printed Name: <br /> Signature: <br /> Date: _2 <br /> Address: Y-?.3 <br /> Phone: <br /> City,State,Zip <br /> - i130le <br /> E-mail Address 6 it <br /> REPRESENTATIVE: <br /> AUTHORIZED REPRESENTATIVE <br /> Printed Name• _21 q-w^- S4-r(� <br /> CompanyNamP• e,)W e I <br /> r • <br /> Signature: <br /> Date: <br /> Address: P.6 <br /> r r 7 Phone:_ ��_33�_r <br /> City,State,Zip <br /> s Fax <br /> E-mail Addres <br /> 1 J c�,4sQ f ; c_o <br /> DEQ License# C/ v2'1. <br /> CCB# <br /> G:IFORMSISEPTjMS,07Auth to Apply doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC <br /> 4 <br /> Scanned with CamScanner <br />