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��,,, MARION COUNTY PUBLIC WORKS <br /> e1� �0"'' BUILDLNG INSPECTION DIVISION <br /> �ij`� �� 5155 Silverton Rd NE <br /> .,rM.: Salem OR 97305 <br /> mil (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Ma 41( '•a c €- , have authorized <br /> (Property Owner./Print Name) <br /> Josh Hansen ( Oregon Sewer&Drain LLC) to act as my agent in performing the <br /> (Authorized Representative/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 /> is aLt Si yves4on RA NE ,s'i - a ag 973Z( <br /> Property Salts or Street Address <br /> And described in the records of MARION County as: <br /> Legal.Description Pat {* C&)wV 33 D oo i occ, Tax Lot#(s) *5 4=9 '5- <br /> PROPERTY OWNER: <br /> Printed.Name: (Y12-fle, -f a dot s <br /> Signature: vim Date: 3 4- 69`0-3 <br /> Address: j . 0 CSC S3a Phone: -50 3—93a- 36134 <br /> City, State,Zip 3 i,V ei-4a(1 l Q R 1732 I Fax <br /> E-mail Address . ,+ d e- -s g)rvi p Q Z D I , CO M <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore.•. e.r& Drain <br /> Signature: Date: I'4-t,Z-- <br /> Address:. P• :ox 282 Phone: 503-874-9414 <br /> City,State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer,com <br /> DEQ License# 38968 CCB# 201683 <br /> G.1FORMS\SEPTICLS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />