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MARION COUNTY PUBLIC WORKS <br /> do BUILDING INSPECTION DIVISION <br /> - 5155 Silverton Rd NE <br /> Salem OR 97305 • <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, have authorized <br /> (Property Owner/Print Name) <br /> to act as my agent in performing the <br /> (Authorized 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 /> /1e�0 ,g�iry //ri frig' .�/�e/h OGe ' ?,7 <br /> • / Property Situs or Street Address . <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) • <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: Ay ✓ e f k5'WG(/ <br /> Signature: = — d Date: y--j) (9Oa V <br /> Addres . A26' ,go)c //lv/ Phone: S73S-- 9/O—yd�� <br /> City, State, Zip /c, h,4/4& • 1?3C/ Fax: <br /> E-mail Address GeA CO i 'fh Civg eiCc j e a4D©- c d/i <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: <br /> Signature: Date: <br /> Address: Phone: <br /> City, State,Zip Fax: <br /> E-mail Address <br /> DEQ License# CCB# • <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />