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[TECCIEBrE <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE - AUG 16 2021 <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MARION COUNTY <br /> i?UILDING INSPECTION <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, k COY o\el L. E L S r. ,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 /> I Q -2 3 Z. <br /> Pro erty 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: ua.roi AtliII►5 LIr <br /> Signature: Date: `j/2-61/Z.o Z( <br /> Address: l: 0. 13on 1 33Z4 `Z1v 13u.'+e S N.>Phone: (5D�q (' l l?j <br /> City, State,Zip 1)e rpp0I-� , Or% 1`13b°1 Fax: <br /> .-4k�T E-mail Address 1is‘n•w Y1nG1...t‘ . C.DirY1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon - r • <br /> Signature: Date: _ - <br /> Address: PO Bo -128 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:\FORMS\SEPTIC\S-07 Audi to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />