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MARION COUNTY PUBLIC WORKS <br /> '' BUILDING INSPECTION DIVISION r <br /> ICI (J�/)— _ \ <br /> —11� i-. 5155 Silverton Rd NE <br /> V" I LI V 1 <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 JUN 05 2023 <br /> 'W Y ht : !N � .c a i us PW! i '/ o.m r on.or. ! Bu Idin In ti s e on c <br /> tP � P MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE yiliflORIZING REPRESENTATIVE <br /> 1 1,it ltiS �Gt 1K� /ee, / �.�ec_` il� y C1eM- P , have authorized <br /> —�-� (Property/Owner' / Print Name <br /> Til SS g :St.,/Pi,f C f��0ii 4;ir) to act as my agent in performing the <br /> (Authorized Represen �1e`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 /> k J /77 / Ian! Rri:Sf= /7UH___5U/ /(e 0R q 732 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 /> D�/4 <br /> k Printed Name. •7 AltA't-<! eyc,C dec.:.4e2 i�4 yPer r_ <br /> lk Signature. - '` Date: c.5 2D2.3it- <br /> 'r Address: r 6AI Rd 4515 Phonc: S63 567 - sT2-4.11- <br /> City, State,Zip 3L5U!ll O e. 173 Z 5 Fax: i-i' <br /> .ct E-mail Address j $g Ai f, eb/1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ,3 -- 5.5 T. . Se-,9J4l <br /> Company Name: 4cfi'oi V f_gi.4_--_-_._--.---- <br /> Signature: ��—J - Date: 7/Ol/// <br /> Addres 54AI;ir_. ier-X e - Phone:5-03- /32-211ol <br /> City, State,Zip_ S Q/e 0LYI11 ! 73/7 Fax: S0 3 - S�5' �3 o� <br /> E-mail Address jr. Qe7IQf df Q;ii A73N?ail. C01'17 <br /> DEQ License# 3�3Z3 -- CCB# _..-.5ci7 <br /> G:FORMS SEPTIC'-S-07 Auth to Apply.doc <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />