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MARION COUNTY PUBLIC WORKS <br /> " 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/Buiidinglnspection C p p Q <br /> ao G <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> y c9' MQ- Vie✓ have authorized <br /> (Property Owner/Print Name) <br /> �n hir /t f a f i/€eV 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 /> 18(aJ ,- - Grovt- Rd, AUK Vdadhilm , OR, 9707/ <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: n of /,,L <br /> Printed Name: Fe /l1 of Vei"v <br /> Signature: �� ����P�✓ Date: %C-Zoz 3 <br /> Address: /ia-W 4,40— ,/ jjE Phone: Co 3-75-2.'73 77 <br /> City, State,Zip t/ov�w Q/l , Fax: <br /> E-mail Address 2ee,-y g en a-7LV.c e v.03/7-74,`/, co—, <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 4r� �n i ��Tt/e t <br /> Company Name: <br /> Signature: Date: 9 6 20 z 7 <br /> Address: /rk 3 V - Phone: <br /> City, State,Zip ed az , 9707/ Fax: <br /> E-mail Address 4' /oh/)411 fi/eeva)oat Low, <br /> DEQ License# CCB# <br /> G:WORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />