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-- .4. <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, SC IrC3 pr\Ct 0 Q 2., have authorized <br /> (Property`Owner/Print Name) <br /> 0-cS Ac(,(v\ i %C ,�''Q c) 7_ 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 /> 1� OSCI e k-e NEY '1 D el-ec\)cA\ OL <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description r'd�13 0 Tax Lot#(s) o s\ W3 UIrA.C 0 3 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: Se Y CA L V c\G (A O Z.Signature: Date: <br /> Address:\r.- OS a \:-Dr° Phone: 6111 LI L4 in. a <br /> City, State, Zip Fax: <br /> E-mail Address 0\\('� C u�S'e (Ciy ( (i yNA Ct t\;CU W1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Oe S\"l t){ p'\a <br /> Company Name: JJ <br /> Signature: _ Date: \ \ I O / 2-7. <br /> . <br /> Address: 1' 030( 9CkV\I-e Vu Phone: 01'1 1-2m o- T 1 C'l C <br /> City, State,Zip Cn-evkG \-S dV_ C Ci A Le Fax: <br /> E-mail Address r\o ( ;oL t 1 PS` (a nva 1 I \C'( )1 <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />