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,op,.., 751 I .53 <br /> MARION COUNTY PUBLIC WORKS ( n -o <br /> BUILDING INSPECTION: DIVISION D ' !1�J/ <br /> 5155 Silverton Rd NE Y <br /> Salem OR 97305 OCT 07 2020 <br /> (503)588-5147 Fax(503)588-7948 MARIONC�.' <br /> http://w w.eo.mar on-onus/PW/Bu ldinginspectioaB ®ING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> i, <br /> D.eLce t , have authorized <br /> I <br /> (Property Ow er/Print Name <br /> .C-5 :See 1.c� V) to act as my agent:in performing the <br /> (Authorized Represenvce/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.IDENTI:FCATION: <br /> k , 8" R6 719/ Avg 5i9b6A , Y.9-30‘ <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> /if.Printed Name: " `96 L4 <br /> 1Signature: i �-� Dater /0/6,� P t <br /> s <br /> or Address: K, yi 7�o 6 Ave 56 Phone 503 .,6 -` 5-57 ' <br /> (I1,City, State,Zip (99/- id-1) 04. 7930-6' _ Fax: W t <br /> °C6r 7 L. ,4) b(Q oZ ,e7 <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 37e 5„5 <br /> Company Name: ,4C-)'I'14, v J cr i <br /> Signature: Date: /����os i <br /> Addres 3, ' t? /f7 4 J;r 5 6 Phone:5.0 3- (737.-2¼'J . <br /> City; Mate,zip e /e if Q / 773/7. Fax: co 3 -Ct9 C <br /> E-mail Address jr. CIt" i 1!{ )D3"Ji<t 1. ('0 <br /> DEQ License,# 3473Z3 CCR# 5017/ <br /> G:tFORMSSEPTIC.S-07 Auth to Appiy.doe <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />