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, <br /> ,, MARION COUNTY PUBLIC WORKS <br /> a;l � „t`"y BUILDING INSPECTION DIVISION <br /> -411�J�" �. 515S Silverton Rd NE ' <br /> _ - ' - Salem OR 9.7305 • <br /> (503)588-5147 Fax(503)58&7948 <br /> http://www.co.marion.br.us/PW/Bui(dingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I. �c n:y.0 ,A Ne..\tso t ,have authorized <br /> (Prom Owner/Prim ame) <br /> . lACJ tI e "1 / v"l 5 I)to act as my agent in performing the `' <br /> (Authorized Re resentaii /Print Name) <br /> P <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 /> 8156 lla«W kk y 5e. Tu.rrttr OR. 913a2.. <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description E nc ,<l reds R«Z 5 e. L e# Ce Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: Px4.14.0wA,41 t.1tivn <br /> Signature: g—�.--L_If _._, • Date: //A2/ao2o <br /> Address: /2S Lya k Ave. Phone: 5-03-IN-487 2- <br /> City,State,Zip 4v ttt(n c f(c /o(2 4 Z 3Zs Fax: <br /> E-mail Address 6cn./a c(San @ ac ac(6,ti.y tar• ye.c of <br /> • <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: `2 1 <br /> Company Na e. Att.Cit.da r r,_ i. `.k,. A.ik <br /> T <br /> SI,[latlir` �, 1, ��1 ` 6p Date: I I PI1a <br /> Address: , lb . '.16.)t—k • Phone: j )3 ' JLj)a? 3 <br /> City;State, ip A Fax, 7 <br /> E-mail Address o i <br /> DEQ License# Q,r,& _ CCB# uC, l <br /> Cr1FORMSISEP'rICLS-07 Rath to Applydoc <br /> MCS.07 Rev 03►10 <br /> SEPTIC - 4 <br />