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04_ t5o5R51 <br /> • 1WARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE JUL 0 9 2024 <br /> IiljjSalem OR 97305 <br /> •-• <br /> , (503)588-5147 Fax(503)588-7948 <br /> http://vcww.co.marion.orma/PW/Buildinginspeedon <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, ti.. RyLou. T) e-\ Nt ELScini ,have authorized <br /> (Property Owner/pint Name)„r1 <br /> t-• .5e -,4•0 bietril to act as my agent in performing the <br /> ' <br /> (Authorized Represen ve/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 /> • P4OPERTY IDEN71FICATION: <br /> g 3 8 Dc,v,i Q-Lce,A4,. Lv‘_ , our3 g 3 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> • Legal Description Tax Lot It(s) <br /> PROPERTY OWNER: <br /> PrintedName: \.) L.ouV7 T\ .e- t 5 0 r› <br /> kSignature: d(tilk- (- 0,-A;c-. (Ler-1'V Date YY\b,‘A C At*- <br /> - Address: N1-„,. . e- Phone:5-63 Vrr k <br /> City,State,Zip A- A.."4/42- = , CYR 3 Fax: <br /> 0. E-mail.Address. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 3-7e £5 /4/f <br /> Company Name: 4C, 1749.44 Pfq; <br /> Signature Date: 7/0//11 <br /> c <br /> Addres . , 300 irc,(414; 5e Phone:Fo 3- 932-- Oi <br /> city,state,zip S 0g I 73/7 Fax: co 3 - 575- i;i01 <br /> E-mail Address y. a(lion 11-q;#1 03 rtica . Gaol <br /> DEQ License# , 1(32,3 CCB# <br /> G:WORMSISEPTICS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />