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tli, 1/4�^tn,,�itit+ j MARION COUNTY PUBLIC WORKS <br /> 41:',':.3""-':..,:i.7.--4=11:2'417.1;:,,, <br /> BUILDING INSPECTION DIVISION <br /> :- � ►�� 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> 4 (503)588-5147 Fax(503)588-7948 <br /> ra" 1st+ " ' VUww.CO.marion.or.US/PVV/Buildinglnspeetion <br /> NOS' CE AUTHORIZING REPRESENTATIVE <br /> I, Berry L. ''�9 14 Y\. ,have authorized <br /> �f-` , �l <br /> J.Property Orwne /Print Name) <br /> y4C:.A V'�1'-1-1.0 a to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluati ,permits,and other onsite wastewate treatment program <br /> services provided by the Department of Environmental Quality or County Agent n the property <br /> described below in accordance with OAR chap er 340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> 190 M .ke 4A) r: *to; 1 .4 73 , <br /> JProperty Situs or St eet Address / <br /> And described in the records of MARION County as: / <br /> Legal Description JpS ebi tiCo:4.30,6 .;Tax Lot#(s)g/a `- 1- 5 . <br /> PROPERTY OWNER: <br /> Printed Name: A, •r y <br /> Signature. !►` Date. 2-1S—A7 <br /> Addres . Walfillair Phone:, " HD&c <br /> City, State,Zip j1D6/116l�� /?47fFax: ��' <br /> E-mail Address /c;czx. er• 7i, .;/ 4:091 <br /> AUTHORIZED REPRESENTAVE: \ . <br /> Printed Name: CA .e}kfr-\ <br /> Company me _ Cit,. - , CkVIC r\O <br /> SignatC.tre ' .. Date: `c,?-5-%--1 <br /> Address: r') i; ��-- Phone: 9T1ue a-4-12 <br /> City, State,Zip Q\jjt`NQr(l Oct, .01.-1-° Fax: eSki?) -1 -.13 OK( <br /> E-mail Addressb 0.G Nra(14VAek-e.S.L, (..fi V1 <br /> DEQ License# r. �\0.k.( CCB# LAQ'S'S 1 \ <br /> G:'FORMS SEPTIC Application Pockets S-07 Autlt to Applv.doc <br /> MCS-07 Rev 03/10 - <br /> SEPTIC 4 <br />