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MARION COUNTY PUBLIC WORKS <br /> d\--(5651 � <br /> BUILDING INSPECTION DIVISION ECENED <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503) 588-7948 MAR 2 6 2021 <br /> http://www.co.marion.or.us/PW/BuildingInspectioARiO��l1s9 "y <br /> n� <br /> DING P <br /> 1T!NG <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 4c. I, Anisa Taft ,have authorized <br /> --�— (Property Owner/Print Namelrl <br /> J S� g :S e irm 1 40 Ovj vef,lei to act as my agent in performing the <br /> (Authorized Represen t ve/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 /> 3 4749 riverdale rd s salem, Or 97302 <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 /> k Printed Name: Anisa Taft <br /> kSignature: jr. �. Date: 3.19.21 <br /> 1 <br /> y Address: 4749 riverdale rd s Phone: 503.508.6780 <br /> 1 City, State,Zip Salem, or 97302 Fax: N/a <br /> or E-mail Address Anisa.taft@gmail.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: e 55 Z .S 4141 <br /> Company Name: C, i t7h 17ccr i 4 <br /> Signature: Date: 9/6rf/f 8 <br /> Addres 417,54 MLC---14016� Phone:-0 3- 732--Z <br /> City, State,Zip 5 Qle Yli l Q 1 7317 Fax: cO 3 - C1) - ��Q <br /> E-mail Address Jr. Q c-i 01 I (1 (�)(3. q;I. C.8'n <br /> DEQ License# 37(3Z3 CCB# 50/7/ <br /> GAFORMS Auth to Apply.doc <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />