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•Aar,,,,,,,,,„ MARION COUNTY PUBLIC WORKS <br /> '• BUILDING INSPECTION DIVISION E (CLOSE <br /> ,il�� 5155 Silverton Rd NE <br /> Salem OR 97305 �uN.3 O Z023 <br /> (503) 588-5147 Fax(503) 588-7948 • <br /> \-1) <br /> http://www.co.marion.or.us/PW/BuildingInspection MARION COUNTY INSPECTION <br /> 1LDING <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, - l j"6'c 1'1 t'Q 'N ,have authorized <br /> o (P�op� Ovgner L� 1 / e fto act as myagent in performing the <br /> �1����G /��/( 1�� �I P g <br /> (Authorized Representative/P Int 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 /> A 4(o/ A Y64 401 okil i Pry-t1?7 0-A- Q71 7 <br /> 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 /> Printed Name: (0c,,A-I-- t .Q2,1 A` <br /> Signature: AA,„ . L Q,,_-- Date:. ,5) (0/Z 3 . <br /> Address: . 29I(01 ,LAQ.v 0 �, Phone: SO3—Sq-GC)a)e <br /> City, State,Zip S+-- f A•4.,I 02... fl I3-7 ' Fax: °.r • <br /> I <br /> E-mail Address e, d.- .. �.✓ 54 IA u I i-e I - C 01•( <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: t41 a /ka> /14 Li p (LAI . <br /> Company N • � €-t.e0?/0- 4 e-S UL <br /> L <br /> • Signature: • Date: ' j Jg& / - <br /> • <br /> Address:_ 1 q 131 . g 1Al2 Phone: <br /> City, State,Zip c -. IIf OR,_ / ,r Fax: . <br /> E-mail Address MA at&Cc-- ac✓e pk.1 5 3 0 fl/ s A1,, Cep <br /> DEQ License# / CCB# /%{�Z,3 L <br /> G:\FORMSISEPTICIS-07 Auth to A.pply.ddc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />