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MARION COUNTY PUBLIC WORKS <br /> 914_�,51? 5 <br /> "��� BUILDING INSPECTION DIVISION <br /> ���1��f�. 5155 Silverton Rd NE <br /> Salem OR 97305 ECE�VE <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection JUL 03 2024 <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, TGr-row /1+1 I&. / ,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 /> 12_82.6 ea r r%5 k b-tp k,C C'R ? 7 3 9z. <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: (3 c rrod .M i 1-z.e/ <br /> Signature: Date: v6/?..yb..o2-7 <br /> Address: /Z E 2-6 PR ry e s b e rk-A-. Phone: 6 I4{— 3/6—5 9 5 <br /> City, State,Zip r/ O R/ 973 9 2_ Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore n Se er& ain LLC <br /> Signature: Date: ?-3•-Zl-t <br /> Address: PO 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:IFORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />