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MARION COUNTY PUBLIC WORKS ECL1 <br /> BUILDING INSPECTION DIVISION VEnn <br /> 5155 Silverton Rd NE JUL 05 2018 <br /> Salem OR 97305 MARIO C�7 <br /> (503) 588-5147 Fax(503) 588-7948 R !LD!NG UN7y <br /> http://www.co.marion.or.us/PW/BuildingInspection L 1 CTi N <br /> 0 C�, AUTHORIZING REPRESENTATIVE <br /> /7/ <br /> I, I LAA„._�/ I ` --- J) . , .- V I e . e have authorized <br /> (Property C er/Print Name) <br /> (,0 1 , r LL-DR] 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 /> Property Situs or Street 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- co, .G err- <br /> / <br /> r- <br /> / <br /> Signature: /! - Date: C7.2-7//1 <br /> Address:3?-5-3 £ " ` at y fin �eI Phone: 503j -13 <br /> City, State, Zip !G[dyj�v a0 1.731.2.. Fax: <br /> E-mail Address 6vnn he jev.5 a Gf u Ado, 00191 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Nd l<5O"i <br /> Company N. I=. %BO L N P-,-6-77D / <br /> Signatur:. -- Date: 7 — OS -- /0 <br /> Address: P D K. 145 Phone: 5-'03 —6 Z 3-05-2"?- <br /> City, State, Zip D01---t— , Fax: <br /> E-mail Address \J i L 11 2 S -3 E co Nwm t, - ( c rV <br /> DEQ License# ZB 0 3 CCB # f c 77 7 4-( <br /> COP--Y Ari AccA✓x{-7oN <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />