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I <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> PL±Lj J V o i have authorized <br /> p (Property Owner/Print Name) <br /> /�`la to act as my agent in performing the <br /> (Authorized Rep sentative/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 /> a,Y. 14VN E Glees. a R7 b <br /> Property Situs or Street Address <br /> New Mxoc_CoaAt5403.0l Coaez /oCRO ,'fi2ES .57 Pei- lzl <br /> Described in the records of MARION County as: Plop:CA3a0-7-V/1-v f7ICD <br /> Legal Description Ga4e,giM (13; 3,FR V ete$t) Tax Lot##(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: PoiI v o\1 <br /> Signature: I' Date: 7-3 1- O,2 I <br /> Address: 'I o 5 '4/at PI 1\1 j Phone: 503-.9( 1—aZ `-)9, <br /> City, State, Zip IeAA) 1OR q'7 3 O f Fax: <br /> E-mail Address no i ce,por e) . 01a11 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: gob <br /> Company Name: Al Sf�✓,c�S �Lc_, <br /> Signature: ��' / Date: <br /> Address: "G 13,x 5) Phone: 5' 89 9Y L3 <br /> City, State,Zip /L9,// c, Fax: <br /> E-mail Address ( /1i,,rJS � n�n.�% e„"vi <br /> DEQ License# 3 9 Z, CCB# <br /> G:IFORMS\She'IC1S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />