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�•„ MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 7"-S1 5155 Silverton Rd NE. <br /> Salem ORFa 7305 <br /> (503) <br /> (503)588-5147 Fax (503)588-7948 <br /> http://www.co.marion.ur.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> h Heather Johnson . . have authorized <br /> (Property Owner/ Print Name) <br /> Josh Hansen ( Oregon Sewer& Drain LW) 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 /> 51471 (3.11yvtiyrk_ Ca- 5 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> legal Description W. ZCi`¢_�Q I v,(l 2 ApcvtSJ fax Lot 11(s) ' >`J '&µ C-C3OC, <br /> PROPERTY OWNER: <br /> Printed Name: Heather Johnson <br /> Signature: Heather Johnson Date: June 6, 2017 <br /> Address: 3161 Ballyntyne Rd S Phone: 503-559-5552 <br /> City, State, Zip Salem, OR 97302 Pax: <br /> E-mail Address hajohnson@aol.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: _Oregon Sew�r 8 am LC <br /> Signature: / / - Date: � L L� _ <br /> Address: PO Box 1282 Phone: 503-8749414 <br /> City.State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License /i 38968 CO) H 201683 _ <br /> I, I I IRMASEPTIC.c.m AuIh to Apply 1°c <br /> MCS-07 Rev Wlta <br /> SEPTIC 4 <br />