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aq-051:114. 1D. <br /> ,el <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION E C E I V E <br /> 5155 Silverton Rd NE <br /> IN/ Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 AUG 16 2024 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, ( dti,Si (e/{ p e;- )have authorized <br /> (Property Owner/Print Name) <br /> Josh Hansen ( Oregon Sewer& Drain LLC) 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 /> l 1,3S lre 26( Air S r . (Orz. 9r73g1 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) Gil /3006 9-00_ <br /> PROPERTY OWNER: <br /> Printed Name: Lt ►carts.. T Ze.,(Ine, a rats A ( d"c e..k. f <br /> Signature: %�ci°4L • Date: _ ' " 15 <br /> Address: ? c ei A 1 Phone: 52 -103 - <br /> City, State,Zip S. I. ck Fob-,.., 6( c 7 3g l Fax: V1(,1 <br /> E-mail Address eiC1 (_ C_:,rr. L'r � T��e.tcif- <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Orego Sewer in LLC <br /> Signature: Date: -oZ!-( ' <br /> Address: P ox 1282 Phone: 503-874-9414 <br /> City, State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 <br /> G:\FORMSISEPTICVS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />