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(CA Upd <br /> '�� MARION COUNTY PUBLIC WORKS <br /> ���� !�"�", BUILDING INSPECTION DIVISION <br /> ►"il � 5155 Silverton Rd NE E- <br /> S FE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspectian APR 10 2019 <br /> MARION COUNTY <br /> • <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 11, )4E9— - av rizl ac►i L l c_ ,have authorized <br /> yy (Property Owner/Print Name) <br /> 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 /> • <br /> described below in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> 4755 ° ..�A... <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> •ted Name: q")p I.-i <br /> e:�- c,✓� N c-,) Date: . rl <br /> Address: t p 7,55 Phone: -9 Jq' —1'/` 7�� <br /> City, State, Zip' r,, 102, 117x5" Fax: <br /> E-mail Address Cia.a•1 1G 43 j p ?A A-, ,►•b -..� <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Tr ► '►�,.r-r <br /> Company Name: rsePei-- <br /> 1.11 <br /> Signature: rr Date: <br /> Address: TC - C) Phone:g2/ ^.5�,-S <br /> City,State, Zip 74 (Y., Cr-1305 Fax: IVA-- <br /> E-mail Address E.Aly/ r -t , aa)e$,P.. � S , C W <br /> DEQ License# /1/4.. CCB# <br /> G:IPORMSISEPTIC\S-07 Auth to App(y.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC • 4 <br />