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I <br /> Q t <br /> 1' !!! NARION COUNTY PUBLIC WORKS (�; E1 V E ..3 <br /> BUILDING INSPECTION DIVISION <br /> .�-=r;"-f�; 5155 Sitvcrton Rd NE i <br /> - Salon OR97305 NOV 17 2021 <br /> (503)588-5147 Fax(503)58847948 <br /> bttp ll ..O.raariO or.usiPW/Buidmginspoctioa yVIARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AITIVDRIMNG REPRESENTATIVE <br /> 4 o < n ,_ have authorized <br /> Gar'43r14Pcirs3wnc LINA,..414......c <br /> to act as my agent in performing the <br /> (Authorizedtative/Print Name) <br /> activities necmgary to obtain site evaluations,permits,and other ondte wastewater treatm►entprogram <br /> services provided by the Department.of Environmental Quality or County Agent on the property <br /> describedbelow in-accordancewith OAR:chapter340,.division 071. <br /> PROP tTXxDEN 11FIC 1TION: <br /> 3 - -- Mioi .� �0 <br /> Property Situs or Street Address <br /> Desch bed lathe records of MARTON.County as: <br /> Legal Description 'TMX Lot KS) <br /> Subdivision,Lot and Block <br /> FXtOPERZ"Y OWNER: <br /> hinted Name: <br /> ta - <br /> Si tnre: Date: Wit.ia i <br /> Address: (v Phone: C�ot.1 S$i-�►� <br /> City,State,7Ap 1St�.kP.De ejf(,.. °IT; Fsx; <br /> -mail Addlress tM- � , cr�q. +,: •eon- J <br /> AUTHORIZED REP SENTATIVE: <br /> Printed Name: v/,/ S%Or4.— <br /> Company Name: - e' <br /> Signature: Date: // / Z` <br /> Address: /7 j''5 e 3P / ,„ 4" Phone: Sl.3 So, /W1 <br /> City, State, Zip ,9-,.4c.----k-t L / 5 7_7d L— Fax: <br /> E-mail Address J -G TCtil ,64---Lee S� , Cc' L <br /> DEQ License# CCB# <br /> G:WORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />