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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> „, <br /> 5155 Riverton Rd NE <br /> Salem OR 97305 AUG 27 2021 -::'/ <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildingInspection MARION COUNTY <br /> Y <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Michael Roantree ,have authorized <br /> (Property Owner/Print Name) <br /> Modine Construction Inc to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> • <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 /> 23980 Summerhaven Dr. N Lyons OR 97358 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Sec. f Ic f3C (w><S c 5 Rg C E Tax Lot#(s) 0 0 3 D 0 <br /> PROPERTY OWNER: <br /> Printed Name: Micheal Roantree <br /> Signature: t.t'ka fR 6 Date: 8/27/21 <br /> Address: 23980 Summerhaven Dr. Phone: 503-949-7699 <br /> City, State,Zip Lyons OR 97358 Fax: <br /> E-mail Address roantree 1 @gma it.corn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Andrew Modine <br /> Company Name Modine Constr ► ion Inc <br /> Signature: AllaTes. Date: 8/27/21 <br /> Address: 5237 Cheha s : . . N Phone: 503-302-4444 <br /> City, State, Zip Ke er OR 97303 Fax: <br /> E-mail Address =ndrew@moconusa.corn <br /> DEQ Licen • # 39331 B# 226250 <br /> G:IFORMSISEPTICIS-07 Auth to Apply.do <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />