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k��� MARION COUNTY PUBLIC WORKS <br /> '��� 1������''' BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> mg, Salem OR 97305 • <br /> (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, SIT-Pol.() T1 1 have authorized <br /> (Property Owner/Print Name) <br /> TVA.� a kto 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 /> /Zvi <br /> Property Situs or eet Address <br /> Described in the records of MARION County as: <br /> Legal Description • Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: S-Fe4 c 1 I ph' <br /> Signature: /8.,��J,_/6L,(1,-- �c,� Date: 2 - <br /> Address:q1 Z? Hav,e 11 prahr '?�� U )VE Phone( cci) &S 9 <br /> City, State,Zip S.1 I neY) O Q: ,f Fax: <br /> E-mail Address % 1 va✓t i ii p►'k.'r1 Q ow?0:1 .Cc <br /> • <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: A/1 I l I' k.' ' <br /> Company Name: <br /> Signature: Date: 2.-1 — <br /> Address: ?"7'F' c'''i I I pfo►I r.`e >T h fE Phon(cOV <br /> City, State, Zip 3.,I-rm oL S 7 50S Fax: <br /> E-mail Address Il0ar) +ipi`f- c' 10 l I. Cdr <br /> DEQ License# • CCB# <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />