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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 555 Court St.NE Room 2260/PO Box 14500 <br /> Salem OR 97309-5036 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://publicworks.co.marion.or.us/building/ <br /> EXPIRED; <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> cf. <br /> � . N.,; v ,have authorized <br /> (Property Owner/Print Name) <br /> "7-:›r f• `�o "�^: Qy / 7 o I I L,•- C8�as myagent 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 /> c> TDB ,( 17 317 Property Situs or Street Address <br /> And described in the records of MARION County as: 2 ?OO <br /> Legal Description D( 20 2y g Tax Lot#(s) - v� <br /> PROPERTY OWNER: <br /> Printed N e: - , �6- o xa - tk. b r''C"v►'t_ <br /> Signature: A- Date: ile-►- J 2027, <br /> Address: 6 31 1/t-11e wow() \br, SF Phone: 570 - 6 c2 ? <br /> City, State,Zip 7)4,ta.4,1 7 3 66 Fax: <br /> E-mail Address Q.& col e <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /pn 2 c t' <br /> Company Name: h rt/A/S /NC <br /> 77 <br /> c, <br /> Signa • � Date: 3 7 L <br /> Address: 77/ /Pie: /`j - Phone: 5-03- 77/ <br /> City, State,Zip Aop,1✓1 G&f 0-4- 9 7f25 Fax: <br /> E-mail Address 7"M Z 6Te ?ac.c.X• C.r <br /> DEQ License# �3� 7y7 72./.r. CCB# PO?? <br /> G:\FORMS\SEPT[C\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/07 <br /> SEPTIC 4 <br />