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4 . . <br /> , . 6, ao/6/o <br /> !1 ���,,. MARION COUNTY PUBLIC WORKS <br /> `iiI ��ii"" BUILDING INSPECTION DIVISION <br /> - .�1j;�� �� 5155 Silverton Rd NE <br /> + ,,.._...._.- __ <br /> NMSalem OR 97305 <br /> (503)588-5147 Fax(503) 588-7948 , <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> • NOTICE AUTHORIZING REPRESENTATIVE • <br /> I, GW.J"1 d a S( (bun Q €-tet 0 • ,have authorized <br /> (Pro erty Owner/Pt Name) <br /> . U w t (''m vi e x-f (1\&t kiwi Drax)to act"as my.agent in performing the <br /> • (Authoriz 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 /> • <br /> 5 uZLE ktaw VIwc.i 5£ Auvm.Sv c I LeO R91 32.E <br /> Property Situs or Street Address • <br /> And described in the records of MARION County as: <br /> Legal Description• Tax Lot#(s) • <br /> PROPERTY OWNER: <br /> Printed Name: Glenda. i I b•tX i�9 2A . . <br /> � �U�- <br /> Signature: zi z,,,s(. v i aL v Date: 3—( --- I c - <br /> Address: - 5 d Up & cW3 RNLI S . . Phone: 503—q 10— 4Z b4 <br /> City, State,Zip km-16u I ( i.2 i OR c1 13?%5 Fax: " <br /> • <br /> E-mail Address CI-2.n 5 i I b tu\FX)4-rna i I r GDYYI <br /> • <br /> AUTHORIZED REPRESENTATWE: <br /> .s. <br /> • <br /> Printed Name: . 0 <br /> Company Name: <br /> Signature: Date: . • <br /> Address: Phone: <br /> City, State,Zip Fax: <br /> E-mail Address • <br /> . <br /> DEQ License# CCB # - • <br /> o <br /> • GAFORMS\SEPTIC\S-07 Auth to Apply.doc - <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />