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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salent OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.orats/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 50 le7,1 /(/,'\C ,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 /> 00 /tr - if 0 S -er114Cl <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Ara./3 cf.' Pkt 1-.2-010 ax Lot it(s), <br /> PROPERTY OWNER: <br /> Printed Name: 7(//ik a T. 054,7 / /r <br /> Sicrnature: 4,, 7 Pate: (,)Cth.,.. – 3/ <br /> Address: OS _ 11. Phoneht <br /> City,State,Zip 574-7),.7677 3a--3 Fax: <br /> r <br /> E-mail Address A a 0, Ail 41 <br /> AUTRORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon el,,z Drain LLC <br /> —- <br /> Signature: ,delAlevicb.. . Date: Cc( <br /> dir" <br /> Address: PO Bo 12r Phone: 503-874-9414 <br /> City,State:.,Zip Silvertan, OR 97381 Fax: <br /> E-mail Address iosh@oregonsewercom <br /> DEQ License# 38968 CCB # 201683 <br /> G:\FORMStSEPTIOS-0,7 Auth to Apply.dQc <br /> MCS-OT Rev 03110 <br /> SEPTIC 4 <br /> _ _ <br />