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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> m: <br /> 5155 Silverton Rd NE <br /> Salem OR <br /> (503)588-5147 Fax(50397305)588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> CMP ROTH FARMS,LLC,WITH MATTHEW&JAMIEE ROTH <br /> I, ,have authorized <br /> SPronerty Owner/Print Name) <br /> Nathan Boderman of Michael J.Pa Iska, C <br /> 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 /> 4914 SHANNON ROAD NE,SILVERTON,OR 97381 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> ACRE 93.46,19-20:DEFERRED ADDITIONAL TAX LIABILITY SB125.18$48.43 071 W06 00300 <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: CMP ROTH FARMS,LLC,AND MATTHEW&JAMIEE ROTH <br /> Signature: P• •_ ( 44 <br /> Date: If.fq <br /> Address: 6791 RIVER HEIGHTS LANE Phone: (503)932-3444 <br /> SALEM,OR 97306 <br /> City, State,Zip Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Nathan Boderman <br /> Printed Name: <br /> Michael J.Paluska,PC <br /> Company Name: <br /> Signature: Date: <br /> 1820,Commercial Street S.E. (503)999-3801 <br /> Address: Phone: <br /> City, State,Zip Salem,OR 97302 Fax: <br /> E-mail Address boded aQhotmail.com <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />