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MARION COUNTY PUBLIC WORKS <br /> ���� BUILDING INSPECTION DIVISION <br /> �%�;e—s,, 5155 S Silva -Rd NE D< <br /> ram Salem>OR97305 " '6 20 <br /> 23 <br /> (503)588-5147 Fax(5,0 )588-7948 - �+ <br /> ttp.//www co marion or ns/PW/Baildin ection <br /> h p �rti . - MARION COUNTY <br /> BUILDING INSPECTION' <br /> NOTICE AITTHO►RLZING REF ER, + iTATI <br /> : c If.;a%( OA/ x/ r1-‘57,./. ' <br /> have authorized <br /> (Property <br /> Owner I Prmt Name) , <br /> fiat f i t rit.-.. to act as my agent in p: om i. g the <br /> {Authorized Representative 1 Print Name) <br /> 3 , <br /> activities necessary to„obtain site evaluations,perimits, and ot}ier ansite wastewater treatment pro <br /> services provided'by the Department of Environmental Quality or County Agent on the property . <br /> described below in accor brace with;OAR chapter 34.0,.division,07t. <br /> PROPERTY-IDENTIETCATION::. . <br /> -��.•• a c <br /> r <br /> P-• Srtus'or Street Address - <br /> Described in the records;ofMARION County at. <br /> Legal Description . . Tax Lot##(s), <br /> .. .Subdivzsiou;Lot and-Block " <br /> PROPERTY OUNER: . • <br /> = Printed Name 6 A 1 i'G e'r .. <br /> Signature Date• /f �3 <br /> Address:. ' $ ►-As f 4" ' Phone i <br /> City,.State,Zip '�/ —I e ' '1'.7.J <br /> Fax• " <br /> kiiiie i 671/, ,,,,e,,,,,,,..„7,,,,,fe,041 <br /> E-mail Ad .dress. . <br /> .. <br /> AUTHORIZED REPRESENTATIVE:: <br /> , <br /> Printed Name . <br /> Company Name• . '' ( �t <br /> t , -, . <br /> 1pc <br /> Sirs atnre; '- :. f4--1--4--- ..... <br /> Date � r� ' .� <br /> 01 5: �Address :� G <br /> Phone <br /> '.---- ,' f 733 Fax 3.`'� '3.- 3 I. <br /> City, State,:Zip [�( .� f <br /> E-mail Address 3 tir-Ol ` biebia . i. <br /> ati- <br /> DEQ License## <br /> CCB# A <br /> G:iFgllgSISEP' ICLS-o7AuTn To-APPLY<DOGXR eV 3110,3/1g <br />