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���� MARION COUNTY PUBLIC WORKS <br /> '1�� 1�����"'' BUILDING INSPECTION DIVISION 3 4- r obi <br /> 11� \\\� � �L J <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 JUL 10 202 <br /> http://.www.co.marion.or.us/PW/BuildingInspection <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, �IkZ,�I u� ��� �� have authorized <br /> roe Owner/Print Name) <br /> p �3' <br /> P4J-UL S 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 /> • <br /> PROPERTY IDENTIFICATION: <br /> - • if r <br /> Property Situs or Street Address . <br /> Described in the records of MARION County as: <br /> Legal Description c)&ted1/4, Oyote)3Oc e:}0Q/9 Tax Lot#(s) 9 0-0 ' <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> V <br /> Printed Name: vaZu Q '_ to ,! <br /> Signature: AWir Date: /611.-.02. <br /> Address: «�R '• , __ /ph' Phone: 7/)roa -0? c <br /> City, State, Zip wArtark / d 7_ Fax: <br /> E-mail Address 4 L d4, z G <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: P &G1Ct S <br /> Company Name: ,QED TA IL Ex C,9 i/A-r1' ✓6--- /4/4 <br /> Signature: ,%7:el ia �,� Date: 7-5-202 / <br /> Address: 4//2/ /2;G/G 1)/; Ste' Phone: Q3- 779- 62 - ' <br /> City, State, Zip %URA/, '/j / OR 9739g_ Fax: <br /> E-mail Address pg.Gr/ e rpJJG/,/ei , Cam <br /> DEQ License# 3g757 CCB# 2',3 7(8 <br /> G:\PORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 • <br />