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���� MARION COUNTY PUBLIC WORKS <br /> .��I 1���ii''"� BUILDING INSPECTION DIVISION ®� ,Fi©E[V E rTh <br /> �ily� � 5155 Silverton Rd NE v LC I`" °`-= Salem OR 97305 JUS 13 '-{j) <br /> (503) 588-5147 Fax (503) 588-7948 2010 —& <br /> http://www.co.marion.or.us/PW/BuildingInspection MARION COUNTY <br /> CU LDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, �'i G�,In !s. • '_ ,have authorized <br /> '.' <br /> ' .erty Owner/Print Name) <br /> �-d r fry . to act as my agent in performing the <br /> (Authored 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 /> qii° Paskrelool iasti2_ ,/k _c§i.L.‘ c ce_ (17,517 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Se, a,4 ,)'I i / des dr ih�rotTax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Nam , I i In ' <br /> Signature: <br /> Date: 6-11- <br /> //�� rr � ii� <br /> Address: / f0 Pcist trt ' 'f / Phone:_50 7-/Z--) <br /> City, State, Zip _ i Q r q � 7 Fax: <br /> E-mail Address ri et,visa G,Q . 0,_ok,-.__ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Cet.,e-0 4, J c.c.a"( <br /> Company Name: <br /> Signature: d_.-/4 /661. Date: ( -// -/f <br /> Address:f3 c,Z /V2r h,",;v-- ,a L S. Phone: ,5`c7.3 - 'f--)776 <br /> City, State, Zip —SIX,.., Ode 9730 6 Fax: . <br /> E-mail Address y,-, heti,0 a-A 0 j u K o _ e.o <br /> DEQ License # CCB # <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />