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r <br /> ��� MARION COUNTY PUBLIC WORKS 41 /y // /n�J }� 1 <br /> All t11jI1M11 _l "'C.✓��y�I`1 �' • _� 1 �I <br /> BUILDING INSPECTION DIVISION 1% rrII cy- 2 i4 <br /> ��1� �= 5155 Silverton Rd NE i,---=) E u v� I'\, <br /> iiii°--------.,,.. :�.,..t. Salem OR 97305 i <br /> 503 588-5147 Fax(503) 588-7948 \ ' 0\.1 2 'f <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> MARION COUNTY <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Jo 4ri/1 41 i ,have authorized <br /> (P. operty,Ow I Print Name) <br /> (,-,v-(< lick/ y� to act as my agent in performing the , <br /> ( uthorized Representativerint 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 /> 2 5867 IP- i ( me, (-qms , Or) --7 <br /> .35 <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 /> Printed Name: Q n n e,b/ /' Z <br /> Signature: (1 /,(//1.) l I - Date: /V- ,az <br /> Address: 5?''2. /1e_4),y--/- ve 5E Phone:56 - y5-7-,z6-at <br /> City, State, Zip AG/6L-7/5 (9 k97 .5( Fax: <br /> E-mail Address JccLhni l"5 O q -/ (a Corn <br />- AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Mark11I-eJk h <br /> Company Name <br /> Signature: /fli 'j i r Date:/i)d). 2--b ' 2-0 <br /> Address: r� • #5 Phone: 5a3 ' ef J. 9cs 2— <br /> City, State, Zip ,I v l-1/1 C f'1 ,/ nr 3 q.-7- 6,D Fax: . <br /> E-mail Address J/1/} V12h f 1V 5 e 9 frina i ? . <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\5-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />