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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> l`- ; 5155 Silverton Rd NE <br /> -s = Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://vvww.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, ( k Pc1-5 a-2— have authorized <br /> (Property Owner/Print Name) <br /> .. z to act as my agent in performing the <br /> (Authorized Re esentative/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 /> 1 Lo---(_ LOD--o dhoun <br /> j Property Situs or Street Address . • <br /> Described in the records of MARION County as:' <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: AA 1 <br /> Printed Name: ' 'lc TL► f"J")C CJ 0 z • <br /> Signature: � Date: 3/ t/Z Z- <br /> Address: [Li 3 O L IZ A Phone: `b 5 -9 /./61 <br /> City, State, Zip W Oc,at,1-3a.r c 1 S�-g 1 a 1 f Fax: <br /> E-mail Address Vci, s 4f c i t oL ti C9-- yam,, I -C <br /> AUTHORIZED Vs <br /> REPRESENTATIVE: <br /> Printed Name: s `I�e,1)1-1a"J <br /> Company N� : 1 I (,t) • <br /> �J✓ti-e— <br /> Signature: YdLtht, . _ Date: , 3 3 G 1-1,Z <br /> Address: pi,7 6 j toil Phone: 3)L3-lr 1 I OZO <br /> City, State, Zip W b� 1 D q 26 i,/ Fax: <br /> E-mail Address Vas S Cr fht-e-& 1(,�_- 19-', z,1 ' <br /> DEQ License# r 1 j 5 gR CCB# Z S <br /> GAFORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />