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• <br /> f <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> 1.11 <br /> Salem OR 97305 ® I C"LS ( I- <br /> (503) 588-5147 Fax(503) 588-7948 n <br /> http://.www.co.marion.or.us/PWBuildingInspection MAR 312021 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> J have authorized <br /> (Pr erty Owner/Print Name) <br /> Rob , $$,i ,Sp,-1 saf`v,/r, Lam. to act as my agent in performing the <br /> (Autho�ed Represe tative/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 /> 13 a, /2;tervr eW .fit- cues or. %7-3v <br /> Property Situs or Street Address - • • <br /> Described in the records of MARION County as:' <br /> Legal Description Tax Lot#(s) O 3C'.24 r.,3,3tcc, <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: i Q <br /> Signature Date:140/60 <br /> Address: Pli x Phone: , " b 0/ <br /> City, State, Zip ))/\.0) QT% 4u) L Fax: <br /> E-mail Address (c4m WU I , <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ,6 liop �/,! <br /> Company Name: .Svc • <br /> �l� v;� <br /> Signature: G /f Date: l)3hal_2_6nn,,2,1 <br /> Address: ,pc. Roc 5) Phone: 3;g? —¢%4, 3` <br /> City, State, Zip /1711/ciiifyi Or, ` -7-36C Fax: <br /> E-mail Address /`j/h,s ers.v a), <br /> DEQ License# 3 1 CCB #�� � <br /> G:\FORMS\SEPTIC\s-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />