Laserfiche WebLink
35c--►7 -o a 49Ss--?grcr <br /> MARION COUNTY PUBLIC WORKS 0 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 JUN 2 9 2017 <br /> (503)588-5147 Fax(503)588-7948 /C <br /> htt ://www.co.marion.or.us/PWBuildin Inspection��� <br /> p ��l11.DI JC INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> /jJr 1 ,have authorized <br /> (Property Over/Print N me) <br /> aQ�i1",62 i�/f3'G,v 5/1-P4/04447/hr 7r 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: S Y\t 1, 0...)A • <br /> A Y r <br /> _ G /� r ?� 1 . .- <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 /> Pr'nted Name. PAN` r U� 4-1-2 <br /> _ <br /> \�Signature: ' � Date: <br /> Address: Phone: <br /> City, State,Zip Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: <br /> Signature: Date: <br /> Address: Phone: <br /> City, State,Zip Fax: <br /> E-mail Address <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />