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� •• MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> � � � 5155 Silverton Rd NE I �t I {�p c-� <br /> Salem OR (503)7305 Ln Lia `1',/ h, '�'/ <br /> (503)588-5147 Fax(503) 588-7948 I AUG2 3 <br /> http://www.co.marion.or.us/PW/Buildinglnspection 2017 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, I 1p.tit ,7 $v-* (33 /2 , have authorized <br /> Th <br /> jt (Prope Oyvner/Print Name) <br /> ek Y v- / an SC r-- to act as my agent in performing the <br /> (Authorizedepresentative/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 /> / 32o rL 1-- 2J 1...1E__ 14L6,.....47 <br /> '-J4C,C ( tj 97o37..— <br /> Property Sits or Street Address <br /> And described in the records' of MARION County as: <br /> re <br /> Legal Description ./ W Sic- 366 Tax Lot#(s) 300 <br /> PROPERTY OWNER: c� ^" <br /> Printed Name: t f �ic,-k6 H+9L <br /> ii <br /> Signature: l a Date: g -15- 17 <br /> Address: /A320 L FPd. '4E Phone:co3- Y89-?52-7 fuel) <br /> , State,Zi So3-y&trisb3 1-,-titA,- <br /> City, p }}wb(..-.4 OIL 57o3Z Fax: <br /> E-mail Address cJS-4r1.. Lkc-r tjj. <br /> t.nor CA/`1 <br /> AUTHORIZED REPRESENTATIVE:/ / <br /> Printed Name: Lel �t�i 0 (/A ✓1 GF e (�- <br /> Company Na j /"IOpp f oei,,,/ OA/J7Pif C3,id a� L�- C <br /> Signatur e`..,„, // �,, _ / Date: 9-75- Z_U/ <br /> Address: it 0. (30i• s7/ Phone5C3-6,3Q 2362 <br /> City, State,Zip f 9/e we4 I Ce 97027 Fax: <br /> E-mail Address ,, - ' _c , < /Lr a • dr ,a <br /> DEQ License# CCB# <br /> G:FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />