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1( t)t L - k <br /> MARION COUNTY PUBLIC WORKS. D <br /> BUILDING INSPECTION DIVISION - <br /> ,—'••. 5155 Silverton Rd NE APR 1 1 2019 <br /> MillSalem OR 97305 MARIONCOUNTY(503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> ltttp wwww.co.marion.or.us/Pw/Bwldinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE, <br /> I, 0rnvta 0. ov ` ^3 et! 13_(:, have authorized <br /> • <br /> 11��� (Property Owner/Print Name) <br /> GE S e ;L d- r.:::Kral) -i t.5 j zic,.. 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 /> v- <br /> Property Situs or Street Address <br /> And described.in the records of MARION County as: <br /> Legal Description C,� p,t .' C i=v..;4- r ,,,:mt Tax Lot#(0 3'1 -3`.. <br /> PROPERTY OWNER: <br /> Printed Name: (j 4, 0. S Wt :, <br /> i' <br /> j " <br /> i ..� <br /> Signature: .,e, • -�' ppp vt t'sz ---- Date C)4/-0'1 C(--tot. <br /> Address: 1156 '.7 i:J, ito3`c.'l- AUL Plione `a° '(cli.-:71, 64/ <br /> City,State,ZipotA ,� 7 <br /> ( ��• � S Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /4)(13', )= St...--)4 C — rn[ !i,6 <br /> �C rri f <br /> Company Name: fl C r t� <br /> Signature: �� . Date: V-- ?" / <br /> Address: d_� 60 X_. l /7 2 Phone: Cl- - - c)-- - \1735j <br /> City,State,Zip rge%e//, oe 4 re) -- Fax: <br /> E-mail Address <br /> DEQ License# 3 5c2/..„3 CCB# -7 57 7 <br /> G:\FORMS\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />