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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> ��il`�� �� 5155 Silverton Rd NE <br /> ( -S5a1l4e7m OFRax 97530035 <br /> 503)588 ) <br /> 588-7948 <br /> http://www.co.marion.or.us/PWBuildinglnspection • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, {e fct et,s-Cs-,a n ,have authorized <br /> (Property Owner/Print Name) <br /> Josh Hansen ( Oregon Sewer& Drain LLC)) 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 /> 251 _ fit c C( v,cu, LK s SAtZ"► o1, cr73e2 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description P arc. 3 Qan r,rsc,-, 1N-Ar zd i E--c iTax Lot#(s) <br /> PROPERTY OWNER: / J <br /> Printed Name: �,��i.4 n !1>h es 1 G <br /> Signature: Date: 2/2-440, <br /> Address: 3 6 2S lvt•v-t c, y E Phone: S a.? —,2'�O-B 1 4 c <br /> City,State,Zip 54 le, Ug_ 9'7x/7 Fax: c.Co?-3 )O —2)2( <br /> E-mail Address 1 r P/+A,440 1I=S i.y c . c.o ,i <br /> AUTHORIZED REPRESENTATIVE: - <br /> Printed Name: Josh Hansen <br /> Company Name: Ore•,'n Sewer& Drain C <br /> Signature: _.---- ' Date: 3-2.6—( <br /> Address: P• : 1282 Phone: 503-874-9414 <br /> City, State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 <br /> G:IFORMSISEPTIC'.S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />