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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> Ue <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, h 64 j lA -111,t54-6C f 1-4/av 4,4 Tr.,/ have authorized <br /> (Property Owner/Print Name) <br /> S LA 1 a (ac: 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 /> ,4779c <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision, Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: Tei (w- eirv�.`c�l . A4,4-el (.2 - j 7 <br /> Signature: �� - CiG? Date: y- —1 Com.•_ I <br /> Address: 49- ,`i e v` , (CR S Phone: Lvl[p- pfd - 4 ea( <br /> City, State, Zip r,,AK,2� , OP q 9 Fax: ----- <br /> E-mail Address —Fe/Iliad's t <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: R r'b.5—S ZZ <br /> Company Name. CO c)3a rC cs✓ r? r'I 1 car o ZLC <br /> Date: <br /> Address: I/7.5 /Mt / :/( �L Phone: 3-7 /0 g f.3 <br /> City, State, Zip v;t,,uer` /® /' 9 73,? <br /> E-mail Address tss/®-r-r-r (It <br /> DEQ License# CCB # !732_/0 <br /> G:\FORMS\SEPTIC\5-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br /> IILi . <br />