Laserfiche WebLink
itlMARION COUNTY PUBLIC WORKS <br /> ���""�� BUILDING INSPECTION DIVISION <br /> -t-S4-12S- ----11MI <br /> 5155 Silverton Rd NE <br /> Salem OR• <br /> 97305 <br /> (503) 588-5147 Fax (503)(503) 588-7948 <br /> http://www.co.marion.orms/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, J Q W\ e 1 q Bowers , have authorized <br /> (Property Owner/Print Name) <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 071. <br /> PROPERTY IDENTIFICATION: <br /> CID J. SP\r\A r\tom 4`kti) \i <br /> Property Situs or Stre t Address <br /> And described in the records of MARION County as: p <br /> Legal Description Tax Lot#(s) ,r CCD5;0,t0D <br /> PROPERTY OWNER: <br /> Printed Name: P5 \ t: I 4 Dowers <br /> Signature: �aiw `> s- _i/a-- Date: 7 - 2 1 - / 5 '! <br /> G <br /> Address: P 0 /130 X /21 Phone:50.3 Si97- 25-27 <br /> City, State,Zip 0. fes CR 773 W 6, Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: t\ <br /> Printed Name: C�-C (! 0� VsNW l� <br /> Company Tl1acne: L. C O Ts s v t3 & <br /> J)J .:_ Q-,31--/S- <br /> Signature: <br /> f • pp s.• _ Date: <br /> Address: 1 ' O. & wX $ 63 y3 Phone: c57>r< - .3,9-sita Li <br /> City, State,Zip Nm vA �, O C C77.306 Far 53 --J 17 -1 <br /> E-mail Address S' p/-Ns:3 ?_L.iUI. cc.r-- <br /> DEQ License.#. — CCB # 1 .--) I to 16 U <br /> GdFORMS\SEPTIC\S-07 Auth to Apply.docg13.5/ <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />