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TEICERVE <br /> JUN 3 0 2021 J <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION MARION COUNTY <br /> BUILDING INSPECTION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildinalnsttection. <br /> 5h4er1, <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Pur:Fulmt,U1 ,.have authorized <br /> (Propertys4vner/Print Name) <br /> Ofb ocina,,r- to act as my agent in performing the <br /> (Authorized Representative I 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 /> (g33 ok 1);//, O016 oe 97375— <br /> operty 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: co 'rs <br /> Signature Date:V5_if,Address• 3,,3 o f Phone3 8 32 7 5 5" <br /> City,State,Zip 5 co .5 #/15 Qez. 7 3 75— Fax: <br /> E-mail Address 3 p us--rsy t..rs sa- 1 . M <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: "12,t,q,, t oohy <br /> Company Name: -c 9-0o L <br /> Signature: Date: <br /> Address:. 1„2 . ' u.) V- . Phone: <br /> City, State,Zip is OR q-70-1 O Fax: <br /> E-mail Address` trJoan Y fZ Q.S ,,�_ e+'"t <br /> DEQ License# ' 'L O CCB#. 2,74,51`()SS <br /> G:IFORMSISEPTIC1Applcation Packete.S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />