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1EC -RIIV =N <br /> eUN 2 2 2021 <br /> MARION COUNTY PUBLIC WORKS <br /> 014k "47!. BUILDING INSPECTION DIVISION MARION COUNTY <br /> �-��` �. 5155 Silverton Rd NE 3UILDING INSPECTION <br /> Iuil <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Lee" Z: ,have authorized <br /> (Property Owner/Print Name) <br /> Josh Hansen (Oregon Sewer& Drain LLC) to act as my agent in performing the <br /> j (Authorized Representative/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 /> 7g64f LAJA.k CA-.4.w ka. AlE. S .I44.% o l_ 973osr- <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Set. Aid Tax Lot#(s) D 6,2 tA)a b Omo <br /> PROPERTY OWNER: <br /> Printed Name: Leo" Gr.Z;/ c✓ Z. <br /> Signature: lot, 7 / Date: H -Se-2eZ 1 <br /> Address: P. b. gox qb16 grey !Cc d k Phone: 41.3-3830,4-'IY4I I <br /> City,State,Zip $sac Ks. c,re " 913o s Fax: <br /> E-mail Address rand 1 itis.giait 4:.1i NA <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore on Sewe Drain LL <br /> Signature: Date: 1-/-l3-Zr <br /> Address: P x 1282 Phone: 503-874-9414 <br /> City, State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 <br /> G:IFORMS\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />