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ION COUNTY WORKS ~�g ` 5fb <br /> MABUILDING INSPECTION IVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 OCT 18 2023 <br /> (503)588-5147 Fax(503) 588-7948 MARION COUNTY <br /> http://www.co.marion.or.us/PWBuildinglnspection UILDING INSPECTION' <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, KQ,YCV1 M• b radl , 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 /> aO521 Bnidf Creek- Rd 5E 5 i'Iv it(ton, DIZ 617381 <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: Karen M. <br /> Signature: 47-NOU14., n'1 <br /> 6-11-007 Date: gill /23 <br /> Address:.2o 2.l E5nci CYCLIC 14 SE Phone: 503-'10-/3 a <br /> City, State,Zip 6.-locelbi OIC. g73gi Fax: <br /> E-mail Address I .rn brad co() in sri• £arr t <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon S wer rai LLC <br /> Signature: Date: -vi-rAS <br /> Address: PO Box 1 Phone: 503-874-9414 <br /> City, State,Zip Si erton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 <br /> G:IFORMS'SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />