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vAt ' '' MARION COUNTY PUBLIC WORKS <br /> 14ir BUILDING INSPECTION DIVISION <br /> 5155 SilverIon Rd NE <br /> Salem OR 97305 <br /> ° (503)588-5147 Fax(503)588-7948 http://www.ca.marion.or.us/PW/BulldingInspectlan <br /> sPecNon <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> ,have authorized <br /> caner/Print Name) the <br /> I r)J J )0W t's._ to act my agent in performing <br /> (Authorized Representative/Print Name) program <br /> activities necessary to obtain site evaluations,permit's,and other onsite wastewater treea tmY <br /> services provided by the Department of Environmental Quality or County Agent1 <br /> described below in accordance with OAR chapter 340,division 071. <br /> PROPERTY IDENTIFICATION: <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: C o <br /> Signature: <br /> Address: I ,Y • Phone: 0(1 \ 'LW)"~l C{ CI <br /> City, Sty Zip (t\'t‘1 t1 hQ 1 07.. n Fax: <br /> E-mail Address l 11\n C�_u 1 •L <br /> AUT____LUZED REPRESENTATIVE: <br /> Printed Name: P,IsA 1 y Tc ra.,,.�.. <br /> Company Name:: �- rT <br /> Date: I�I2 J/23 <br /> signature: - —9�c?S� --� s"1 <br /> Address: 169 t e ItrA e I'e) Phone: SC� <br /> city,state,zip fibArr ©i(. 9 7U7I Fax: <br /> &mail Address_ ;k A i; 7i^( yA I,,w,cC... <br /> DEQ <br /> Liceitse# 3 9 pq Q 1 qc1/ ccs 217 863 <br /> A�►as APPtliOC <br /> &ICS-07 RayOy't0 4 <br />