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� • MARION COUNTY PUBLIC WORKS y�/�// ((-- p -r�-�` <br /> .n1 4p,I �-00WQJ-, • .O r <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE (f MF <br /> Th <br /> Salem OR 97305 <br /> ins (503)588-5147 Fax(503)588-7948 I- AUG 2 3 2017 �J <br /> http://www.co.marion.or.us/PW/Buildinglnspection t C` <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE" AUTHORIZING REPRESENTATIVE <br /> I, Atari 6. Sklib/tc✓ , have authorized <br /> 1111 JJ (Property Owlet:/Print Name) <br /> Ia VICt�1 C I et n 4 Pr to act as my agent in performing the <br /> (Authorfzed 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 /> /S300 6heH'& NE {luno, I f7eC 99-032- <br /> Property <br /> 9-032Property Situs or Street Address <br /> And described in the records of MARION County as: �L <br /> Legal Description Li I y-/ cefek� 1TO <br /> -c& B Tax Lot#(s) (J <br /> PROPERTY OWNER: <br /> Printed Name:Name: ithi 0. Lbw bLu r <br /> Signature: F 7}, Date: � /, <br /> � 420/4. /` <br /> Address: 18'3 �oherl- Rc-1 NE Phone:9n1-338-36/9 (Ce/) <br /> YZipf�u Glwrcl 5o3- 982-0/03 ((a,ta fa& <br /> City, State, OR 9'3-032 Fax: <br /> E-mail Address mSMesrl/notes (Oi I Pn5• tom <br /> AUTHORIZED REPRESENTATIVE: <br /> ''� <br /> Printed Name: ZG-v-r l J , r'v e t'• <br /> Company NBA/ • n.• . • u • a _ <br /> Signator a:EA , 1n Date: g - /5- 7DI -7 <br /> Address: , lJ. 5 - 5.K1 p _Phone: 670 —y.362 - <br /> City, State,Zip ? C apo (•^1 0 I` c onZ Fax: <br /> E-mail AddressL,p��� C e S' C-'pi? RLC cS'SS, G0)-v1 <br /> DEQ License# CCB# <br /> G:FORMSSEPrtCCS-0)Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />