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JUN 14 2022
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<br /> ,i0 t.,, „z„, MAttiON COUN 1 Y _PUBLIC WOK BUILDING INSPECTION DIVISInEgviARI N COUNTY
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<br /> miluniii-- -------. 5155 Silverton Rd NE 6 ILDIN INSPECTION
<br /> ME Salem OR 97305
<br /> (503)588-5147- Fax(503)588-7948
<br /> httPaiwww.ca.marion.or.us/PW/Buildinglaspection
<br /> NOTICE AUTLIORIZING REPRESENTATIVE
<br /> ,have authoriz
<br /> (Property Owner/Print Name)
<br /> to act as my agent in performir
<br /> (Authorized Representative/Print Name)
<br /> activities necessary to obtain site evaluations,permits,and other onsite wastewater treatment P
<br /> services provided by the Department of Environmental Quality or County Agent on the proper
<br /> ..,,
<br /> described below in accordance with OAR chapter 340,division 071.
<br /> PROPERTY IDENTIFICATION-
<br /> Og-
<br /> Property Situs or S eet Address
<br /> ri And described in the records of MARION County as:
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<br /> Legal Description
<br /> Tax Lot#(s)
<br /> .t.:„.
<br /> PROPERTY.OWNER:
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<br /> ,........
<br /> Printed Name: - I '
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<br /> Signature'
<br /> Date: Lt v
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<br /> - Address: 1...0.9--)ox Li—ny Phone:5D3-.1-11
<br /> 11 City,State,Zip Se.1.0 no__ 9730 rt__ Fax:
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<br /> E-mail Address Ec..cA.A-ic,62...r ) 31,,,ARL,I • Lc),•-;
<br /> AUTHORIZED.REPRESENTATIVE:
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<br /> Printed Name: cc,,,,„ IAA uvp iA,Li
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<br /> Date:
<br /> 11 Address: e_o ..ez:,ox 14.0 I Phone: sr2-1-
<br /> City,State,Zip 1.4...,12 ..S_ Fax:
<br /> E-mail Address EL nt,4toe-,c ‘....-.4.--i I• ( at. -
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<br /> CCB# k7-1 cj
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<br /> DEQ License#
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