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f <br /> 11 14,,=, MARION COUNTY PUBLIC WORKS jECEFVEI , F)) <br /> ',141''' BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE NOV 2 9 97 <br /> .. , Salem OR 97305 Z�..� Lt--71/ <br /> (503) 588-5147 Fax(503) 588-7948 MAR ION COUNTY <br /> http://www.co.marion.or.us/PW/Buildinglnspection BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, I Vhn peM ,have authorized <br /> (Property Owner/Print Name) <br /> ®Ir to act as my agent in performing the <br /> (Auth �zed 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 /> Property Sims or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) 09,f2WW AObb?bO D <br /> PROPERTY OWNER: <br /> Printed Name: X h i �. Ur QtAker- <br /> Signature: v'V'lnul1Ci4vmp.A7tikr- Date: II"ZI - <br /> Address: y,l)4. S tkkote, \W &S Phone: <br /> City, State, Zip S(X A I. C -Q13a2 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Ek( )- <br /> Company Name: <br /> Signature: 0[10 40 Date: it12.cilwii <br /> Address: ) ) (' rnarkm OA, S Phone: CIA—% NC( <br /> City, State, Zip - \f 1( L R 1 1 Fax: <br /> E-mail Address OJ )COWY\ \A � (OM <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />