Laserfiche WebLink
1 8- <br /> MARION COUNTY PUBLIC WORKS <br /> "11!,= BUILDING INSPECTION DIVISION <br /> i �� 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> _ http://www.co.marion.onus/PW/BuildingInspection <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, <br /> Lea A colle_ �t <br /> -h , have authorized <br /> (Property Owner/Print Name). <br /> pitto 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 /> i 76.8 L ,d. z_ Guaa(-4e1 d970 2 0 <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 /> c <br /> Printed Name: l e0/1 Ar P t 0 4 ,. <br /> Signature: i/ �,' , % - Date: <br /> 0 A� / & <br /> Address: /a .-265z. L Gpk L,ql-c Phone: <br /> City, State, Zip e .J2C-- l2 Fax: <br /> E-mail Address <br /> • <br /> AUTHORIZED REPRESENTA . <br /> 5 <br /> Printed Name: /4,./ e— <br /> Company Name: // /- r ( .C j <br /> Signature: ,, _ = -''/ - - Date: td /� <br /> Address: Pd / c-)ç / Phone: 2' `��/ <br /> City, State, Zip � � /SC/14� ,� j'�' C3 Fax: <br /> E-mail Address"/.. c 424/ , y,Lc, Tc�,jQ,..i <br /> DEQ License# s7g CCB# A(/// <br /> G:IFORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />