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illECE1VE <br /> • wh yMI MARION COUNTY PUBLIC WORKS MAY 2 2 2017 ---jBUILDINGINSPECtION DIVISION <br /> '"':`i' 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> http://Kww.co.marion.anus/t'W/IIuildinginspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, i 6(l47:-,S q 6 L,O 1 A tic N ,have authorized <br /> jProperty Owner/Print Name) <br /> kr-piT A" iA H 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 /> 2G`f L. K o�Yr6 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OW-NEER: r <br /> Printed Name: <br /> ( l eLreSG `)((.kb h <br /> Signature: `J �C i 1 Date: '-f 0 <br /> Address: 61,q) -il 60 ie Lei S Phone: <br /> City,State,Zip 5(2.(e W1 0 ci 1 3 0(0 Fax: <br /> E-mail Address 'I?Ve.S C.. (l (, JY1 f YVtAet(te3eev ii f< CA vt' <br /> .1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ie.-A-t— V,,,,-6-,a^ <br /> Company Name: Koo4c..A.N Fo n e4 I h c- <br /> Signature: Date: &/).---/1- <br /> Address: 3 6 L- K....c,/";,, 14/j, SC Phone: S 0.3- )0- R.3 i a <br /> City,State,Zip S,(a.,,.,. 1 Oe_ 5 7 3 17 Fax: Sod— Z7 o-2--)-2/ <br /> E-mail Address (fie„-r a _ lL utw,,,, it,0,-1..1 I ne. c-o r1 <br /> DEQ License# 1,326 7 I rC. CCB# SS y Z I <br /> G:WORMSLSEPTIM-07 Auth to Apply.doc 44., (S S c;PT,C <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />