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,_4: <br /> 111 <br /> I ^, <br /> FEB.1 6 2022 7 <br /> MARION CUMIN UY"'UMW WUHAN <br /> MARION Cati.,31\ITY <br /> BUILDING INSPECTION DIVISION <br /> UlL.DiNG ll°44P:ECTiON <br /> Salem OR 97305 <br /> ,1 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.eft.marion.or.usrPW/BuildingInspection <br /> I . <br /> -:: <br /> q i NOTICE AUTHORIZING REPRESENTATIVE <br /> II< <br /> !1 ,have authoril? <br /> to act as my agent in performil <br /> sctvvi iit.twei,m1(Proper(ty;weri /,e,er soPrinet vis:Namse)) <br /> (Authorized Representative I Print NIrric) .. <br /> t 1 activities necessary to obtain site evaluations,permits,and other onsite wastewater treatment p <br /> '41 <br /> services provided by the Department of Environmental Quality or County Agent on the proper <br /> V, described below in accordance with OAR chapter 340,division 071. <br /> 411 <br /> 11 PROPERTY IDENTIFICATION: <br /> 1 114'L VIA-01.C.10A,1 U/t- P---' De-kf64 ("112_ 9-43V__ <br /> .. ..::i 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 /> • I Printed Name: OrY1C.id ScIA0-CriNSA <br /> Signature: c.r..,--rj_,I.,,,,fr------- Date: <br /> ',......7.- <br /> n Address; T)?S-- cF ikuy` 7 19 _ Phone: i - , -930 <br /> 1 City, e—ty,State,Zip bOi:i:r.c.. r) 9-2(AO cl Fax: <br /> i <br /> ,--, <br /> E-mail Address <br /> i <br /> !,- AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ,Satit--, 1/1-4411A,t1 <br /> iCompany Name: <br /> Signature: _ 1,--t,--24 <br /> , .&_.,i4" I ii0/ 0, CI-73%-S Date: <br /> Address: 0 <br /> 71/1-5/2.2— <br /> Plione:41,3-14.1-2-77 Z_ <br /> City,State,Zip q _ <br /> Fax: <br /> E-mail Address j7--'(otitiLAI-OAL G cAz L• <br /> DEQ License#.... ( 2-1-6c/ CCB# <br />