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sss- \-;. - Q`-4e\s - QQZ <br /> �'^ ` MARION COUNTY PUBLIC WORKS <br /> ��� °' BUILDING INSPECTION DIVISION <br /> %���` 5155 Silverton Rd NE <br /> - leC \\n <br /> Sam OR 97305 VIE/ <br /> (503)58&5147 Fax(503)588-7948 J <br /> http://www.co.marioo.or.us/PW/Buildinglnspec o OCT 05 2017 <br /> \L-5 <br /> MARION COUNTY <br /> NOTICE AUTHORIZING REPRESENTA7DING INSPECTION <br /> I, Rocio Sixtos , have authorized <br /> (Property Owner/Print Name) <br /> Lil'Slinky Environmental Service 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 /> 22015 Camellia Ave NE,Aurora,OR 97002 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description t' ( 1O 6 i q Tax Lot#(s) 75CO <br /> PROPERTY OWNER: <br /> Printed Name: Rocio Slxtos <br /> Signature: ?NW° 5X{-05 Date: 9- I- /1 <br /> Address: 22015 Camellia Ave NE Phone: (503)287-7743 <br /> City, State,Zip Aurora, OR 97002 Fax: <br /> E-mail Address roxa100211©gmail.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: C,v'.rls Cy 61(.Y - <br /> Company Name: 1,.1! (�J,I/ I C�' IV11onyvvimbJ,I St(vict. <br /> Signature: ( ---e ( Date: 9, )U_ 7 _— <br /> Address: ),90-1?; KOLNs-c‘.1(.. <br /> tel Phone,,,���jjjlr-81 <br /> City, State,Zip (tS-4 n� \ - el _c)7( jc Fax: O�\-)oU--7 p <br /> E-mail Address cLt I,C 0 )).� (-NV-- <br /> DEO <br /> -hr �j ./ <br /> DEQ License# 3�-N '3 CCB # I X 1[p93 <br /> G:\FORMS\SFPTIC1S07 Auth to Apply.dw <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />