Laserfiche WebLink
Z 3 LH Z. i4U--y- <br /> MARION COUNTY PUBLIC WORKS 5 {E C IE v E <br /> 'uIr BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE v 25 2 2 <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MARION COUNTY <br /> http://www.co.marion.or.us/PWBuildinglnspection BUILDING INSPECTION <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, e 1:0 3 , have authorized <br /> '(1 toperty Owner/Print Name) <br /> I-)C.t,v\ < r 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 /> 2215 0 KA gai oli,s a Gl 5 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> . PROPERTY OWNER: <br /> Printed Name: aiit./1 -reo <br /> / <br /> Signatur t � Date: ���f z <br /> Address: 2/Z1. t > �-ork Phone: 13 (t)Z 1 6 3 g <br /> City, State, Zip . L-yGv►,S 'Y 1 -358 Fax: <br /> E-mail Address k cap l gs ,` ' cow <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: a-144,d S L1�4,t <br /> Company Name:e!e - S& ' (7` h <br /> Signature: / ` . Date: 5/ / <br /> Address: 2 2°f ttpu die c1 Phone: /' " 35' T I <br /> City, State,Zip i Lt Vv /v d 61 1 Y 2- Fax: <br /> E-mail Address 0-Fe C{. Sa44.) &(,1'Yl S f'i1 'G0w 1 <br /> DEQ License# Z 39 I CCB # <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />