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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION LIAR 2 <br /> EVEl <br /> 5155 Silverton Rd NE �o�8 C�7 <br /> Salem OR 97305 PviAFliOi� COIJiVTI' <br /> (503)588-5147 Fax(503) 588-7948 <br /> Sl1ILDING INSPECTION <br /> http://www.co.marion.or.us/PWBuildingInspection (�-- 2((pi <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Ce4-LS'?),-v6IL ,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 /> 3v..3 L.u(u L ale G 12 g-1 V.3(., <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Antrs a,ere Tax Lot#(s) G'g34) 324 OCZGG <br /> PROPERTY OWNER: <br /> Printed Name: 5 e Si s lP <br /> Signature: Date: 3)--/» <br /> Address: a3 23 Lu?,t LvL Phone: <br /> City, State,Zip SG.,k - � O 12 4`13Gk Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Orego. Se r & Dr <br /> Signature: Date: 3 2 G- e <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:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />