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• <br /> MARION COUNTY PUBLIC WORKS D g. 17 M <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE i.; <br /> NOV 15 <br /> 51 97305 2017 <br /> (503) 588-514747 Fax (503)588-7948 •,dr ,OIxl <br /> www.co.marion,nr.us:PW/Buildinglosprction ti' 'i.DENG 1"VSPEU;)-1oN <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 0./Cc)cil-Vari , have authorized <br /> KeVi(.,ePrhope �OriwnPrn Pri✓iy <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 07L <br /> PROPERTY IDENTIFICATION: ��7 <br /> (9L1le7 ' 119'4--6h gal- mer Ott 97312-' <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: p� <br /> Legal Description 012127 O 5- 77 Tax Lot #(s) P...3C 9 I <br /> PROPERTY OWNER: <br /> Printed Name: , I'l Lie r L7 __ _Oar <br /> Signanue: W('L/LL(4. ... . ._... Date: II/ 9717 <br /> Address:_ 3�! �F'(»�(•s /� ;5 �,._ Phonc:SC3 D ) : Z3 <br /> City. State,Zip l e yyI 1} -r 73 t).L Fax: <br /> E-mail Address (JL^YU wvl 7 g C yh (t d. 6.41-Th <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: :021- <br /> Company Name: 0/4/6"g,/ (//jv3-f✓L-VC /NL <br /> Signamrc -- _ Date: /70 /7'7 <br /> Address: TO`&O)c ,-27/51,-27/51-6?(/ Phone:., 713 - 5'32 - !(/2 (o <br /> City, State, Zip /7/ALF O"2 __.12_712.7 Fax: <br /> E-mail Address ysp!-fG, (a-.OGe/I Cpl? L'T/'/rCfQ,57/4 <br /> DEQ Licenser �� C3 //JCCD# `0 S' (p/ <br /> f1 <br /> G;FORMS SEPTICApplication Packcu S-07 AutM1'r Appy doe <br /> MC&C7 Rev 0310 <br /> SEPTIC 4 <br />