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.,,,�������1` MARION COUNTY PUBLIC WORKS <br /> ,Ii .1 BUILDING INSPECTION DIVISION <br /> -�►�j�`� �� 5155 Silverton Rd NE <br /> 8 5147 inv. Salem Fax Fax(503)588-7948 EXPIRE D <br /> (503) 58 <br /> http://www.co.marion.or.us/PWfBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Wrs- © l LC , have authorized <br /> (Property Owner/Print Name) <br /> Katie Ryan 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 /> s o ,,. - S+ I (- <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 N • i,I S Q tv_.(.,c. <br /> Signature: t,",,,A 'o,,,--4,1 AL, ) Date: i j al )al?Z <br /> Address: 1a.4 S' yA•'i-„ S-i- c 6- Phone: SOJ- S 646- 01 N 3 Pi <br /> City, State,Zip c cs, .c o___,-. g1302 Fax: 9?1-273- )5'ci7 <br /> E-mail Address O v7.1 CA_, A-o v►.,1c,✓• Q 0.0 i Co w1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Katie Ryan <br /> Company Na e: he xc sting <br /> Signature: Date: <br /> Address: PO Box 504 Phone: 503-743-2343 <br /> City, State,Zip Turner, OR 97392 Fax: 503-743-3638 <br /> E-mail Address officeAbethelexc.com <br /> DEQ License# 36198 CCB # 44551 <br /> G:tFORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />