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as5 - - -ook.`6Sek• <br /> t��,�,, MARION COUNTY PUBLIC WORKS <br /> .,I �,'''! BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE -� <br /> Salem OR 97305 VU U 11 l� <br /> (503)588-5147 Fax(503) 588-7948 J <br /> http://www.co.marion.or.us/PW/Buildinglnspection JUN 26 2017 k(S <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> A\L v z-- ,have authorized <br /> Property Owner/Print Name) <br /> 3. ` C. r � to act as my agent in performing the <br /> (Authorized Representhtive/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 /> 835( rr wood Pc A-402-s <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: F 14( t(2-Cf/1( <br /> Signature. a. � � Date: 62-094.0— I"l <br /> Address: 0 cg, 6. -sif 9j,6' J. 'hone: <br /> City, State, Zip (4Q) 02 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company N-..e: _144+ <br /> Signature: 1116 Date: _ e O_&(, <br /> Address: / O. P '( qq3 Phone: <br /> City, State,Zip C‘.'.1 ?"73(, Fax: <br /> E-mail Address 56c_ Oa 0.3 0.__W U I, w <br /> DEQ License# CCB# /7! (p$t/ <br /> G:\FORMS\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />