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„l' ,_,...„, <br /> ®, MARION COUNTY PUBLIC WORKS <br /> REcE[N ER--11 <br /> ` ”"' • <br /> BUILDING INSPECTION DIVISION <br /> �J-» 5155 Silverton Rd NE <br /> = Salem OR 97305 • SEP 24 2018 C<7 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTf <br /> http://www.co.marion.onus/PVV/BuildingInspeetion BUILDING INSPECTION <br /> \ 4S '00 725 <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 4N\Thk,-n G rat , have authorized <br /> V�/ � (Property Owner/Print Nam4) <br /> -4 -e' _, -/,,(\- t7'{- \ p n,l,r `` \ ke k to act as my agent in performing the <br /> Authoragr 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 /> 537() 4..k..._ J-61.1:1,5,1ç2,/. N(.. ga-on aQ. 3a.r° <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 4 15-1 .LeJ,.51—. (10,,j,cr Tax Lot#(s) Li_ Frei8 <br /> PROPERTY;OWNER:. <br /> Printed Name: A-...\-v„„n L G,Pe tv._ <br /> Signature: ,r,,`„..., /.9 << Date: 4) .) 3) 1e <br /> Address: 5- 5- S P 6411..%c. )4y'>' 7,1fitx,i 9'110 Phone 5 61—4;1--c,303 <br /> City, State,Zip V,e.lc"„1 U.., 1131.1 Fax: <br /> E-mail Address. .. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: C.1'11\\ \Q. ? `: Y-\Cli:H.W. <br /> Company Na e:f��', _. <br /> ,, ` (, .X)R, 1 , . <br /> Signatu.e . ! - `J Date: <br /> Address: r. 9-11,3)/ --� Phone: 9,-)'.r-�--1 al-IS <br /> City, State,Zip-1\y‘ vA ()() U1 ? Fax: C J. U .-1-47) c <br /> E-mail Address D\U( \n 1-. „1cC .(0:Yl <br /> DEQ License#?i, .\C)\'. CCB# L--{L`.G)(.6,. <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />