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t�, MARION COUNTY PUBLIC WORKS <br /> '�� ���''"'1BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> (a ,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 /> S'940 ( ICS. <br /> Pro1erty Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description /eve-5 I, I Tax Lot#(s) ej"Z/'`)!leg— ® 1100 <br /> PROPERTY OWNER: ,l n n <br /> Printed Name: ` ��1 <br /> Signature: Date: <br /> Address:. 6 Phone: 5- 5 —2f- <br /> City, State,Zip W i �5crc v (J - (7 Z ()Fax: <br /> E-mail Address,r f . 9 U li/1)e� 11C. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore•dt, er& Dom, LLC <br /> Signature: �/ Date: a[-[r <br /> Address: PO =•x 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:\FORIvIS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />