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• <br /> 1 SCE{I <br /> J, <br /> c'-7 <br /> �,��,,,,��,,,,� MARION COUNTY PUBLIC WORKS MAR 0 7 2019 <br /> ,n <br /> BUILDING INSPECTION DIVISION <br /> % �. 5155 Silverton Rd NE MARION COUNTY <br /> ----,, , ,.. BUILDING INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503) 588-7948 -00/71c <br /> www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, lArr�1 L. 40 it ,have authorized <br /> roperty Owner/Print Name) <br /> p �J <br /> +�1 e--PA�I }=,e.-jl V%F j-)DA/ 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 /> 7 <br /> 1410 /44c141 40 a D -filea 04 139z_ . <br /> 4 Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description /T E O IA C O:4'30 ts, Tax Lot#(s)g/vr. f 41- <br /> may c,.e 4 /;A:®N, 09g 25" <br /> PROPERTY OWNER: // <br /> Printed Name: /4 hr 2 . LC�tA <br /> Signature. ...7 Date: 2-13—/i7 <br /> Addres . ,[ y( 72 Phone;, 579.3-giagc <br /> City, State,Zip a®pe1/4 N,i1 42/Z 9757/ Fax: e <br /> E-mail Address /® ,y. let,r y _1,6 �,1. ,�,e i /, �v71 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: \e- <br /> Company lime: ',r." ' W C( <br /> SignatIPN. ‘ Ibi Date: (?) S--M <br /> Address: Cii0 .7)4 0 Phone: SU6 1L1? r jLia <br /> City, State,Zip QX,`s'Nl( M., °\.---I- 1' Fax: SO-1 yLQ l e>lr <br /> E-mail Address DK LO @ \(aei ,L, con, <br /> DEQ License# A_OlIc CCB# qU S1 <br /> G:\FORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />