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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION FEB 04 2019 C�7 <br /> =�i� • � 5155 Silverton Rd NE MARION COUNTY <br /> _ = m Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503) 588-7948 I cl _CDcb 37 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> Cocom In <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, J t ,have authorized <br /> (Property Owner/Print Name) <br /> ck4) c\\(Q <br /> to act as my agent in performing the <br /> (Authorized Rep entative/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 /> 32,57 . OU ktd. . +7, KJ61,,AL4 1467, <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: <br /> Signature: Date: /2-4 . <br /> Address: / ‘553,1 S L' I tXkS Phone: 5 6 °S <br /> City, State, Zip ?A/WCr-, A OR. 4'3-21 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: (-NC.X,"\A-e \LI\ <br /> CompanyN e: bCO,,\D(N'h <br /> Signature. • \ Date: <br /> Address: Phone: <br /> City, State, Zip Fax: <br /> E-mail Address <br /> DEQ License# CCB # <br /> G:\FORMSISEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />