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�����, MARION COUNTY PUBLIC WORKS <br /> '1�� ��il'''*, 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%PW/BuildingInspection <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I ( Lciói6p rI V D6 I ,-e4 have authorized <br /> • <br /> (Prerty Owner/Print Name) <br /> Fr 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 /> 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 /> - <br /> Printed Name: -(eft. F . ( v �` r <br /> Signature. , ��_ Date: 2 j /© <br /> Address: p 4 ° , j o r 5-6 Phone: . b3, S 73-5'7 /'Z- <br /> City, State, Zip S G 0 ( [ , S/ D ze, 973 3 7 57 Fax: <br /> E-mail Address <br /> • <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: - ka ( 5'çei(l a v <br /> Company Name: 5e, w,t (4 ;AAcs LLC. <br /> Signature: Date: O Gf 36 2.0 s,. 3 <br /> i <br /> Address: ��lo l 6 f'be4'� c 1`4 lie. Fs,A. ►`V E . Phone: 51)3 -<8 7 1-3 0 0 <br /> City, State,Zip 9.7303 Fax: <br /> E-mail Address icq e� vvl q tn1� C t� <br /> DEQ License# R, i 7 c9 CCB# Ica$ I • <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />