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-6/03gi-- <br /> MARION COUNTY PUBLIC WORKS <br /> "'" BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax (503)588-7948 <br /> http://www.co.marion.or.us/PW/Buildinginspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 61-eveBr a+?� Pr'L°Sij2rlf Ady^v? C 6 rpardthave'authorized <br /> / -.„ (Property Owner/ Print Name) <br /> DA/4; ! t Re.t 5 S 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 /> 3 V8 73 Al r i FO'k Rof L/onc t OR ?735�' <br /> Property Situp or Street Address 'w <br /> And described in the records of MARION County as: <br /> Legal Description O'5yE3rowar Tax Lot 4(s) /00 <br /> PROPERTY OWNER: <br /> Printed Name: E/ Aern C/D sieve 8v�N,e1?// 4-esiie / <br /> Signature: n �- Date: /D/3/_20.2% <br /> Address: (US�3 sevei7'i /oDt;ur7`�//;•., Dr.! 13�uX 2R Phone:lS'V/,6I7`Jy4y <br /> City. State, Zip 8e--J D R ?77'2 Fax: _._.. <br /> E-mail Address � EQ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: --D1,1/7/ L cJ <br /> Company Name: • - , Co/?5c(Lp)/ ) <br /> Signature: / Date: /0/ill2 f° <br /> Address: l /C/ 3 -/6 Al�i . AJ DTI Phone: ,-C /L' '/941 <br /> City. State, Zip '54 jOf ` L� --- `I-733' C " Fax: <br /> E-mail Address d 4 y7 [L a g.�j, / 1 <br /> DEQ License# CCB # <br /> ti:FORMS SEPTIC S-07-loth to Applv.dck _. <br /> MCS-07 Rev 0310 <br /> SEPTIC 4 <br />