Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> ! 61SS Silverten Rd NE <br /> r = - Salem OR 97305 <br /> ( S3)6S0-6149 Fax(UOS)600-79-:s <br /> `..:_`.. ; lisittp://www.copmarion.mus/PW/BuildingIvaspection <br /> NOTICE AMMO I ZING REPRESENTATIVE <br /> I, <br /> aA' ro / E I�� C'�!'Ja,o ,have authorized <br /> roperty Owner/Print Name) <br /> Be. to act as my agent in performing the <br /> (Authorized Represenntat ve/ t 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 /> ,5L 1.VeA Cues-1 L4 , 3a <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description P.P. Apole-6Ss •ac4.2. ,pI Tax Lot#(s) <br /> PROPERTY O`iWNER y <br /> Printed Name: (A-1-i Gk /Ll t let�,v <br /> Signature: ' Date: 2 <br /> Address: .C a a a Ili A G/- £ Phone: 9)7_ �O7" °l q 7 <br /> City,State,Zip ca l2 IM, 0 o, ? 30 6 Fax: <br /> E-mail Address / G A • ¢- At of `I 6.6 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: O 1_W\Uk <br /> Si naturew IANLIi'llDate: A Ii rL1 <br /> Addres .Ii1�1►�` � Phone: 11,41 _ 33(773 <br /> City,State,Zi. Ilk e l� 7 "IP Fax: <br /> E-mail Address u (j exc <br /> DEQ License# i CCB# k-C Ll 511 <br /> ONORMSISBPTICiS•07 Auth to Apply.doo <br /> MOs-07 Rev 09/10 <br /> SEPTIC 4 <br />