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i, <br /> ���� MARION COUNTY PUBLIC WORKS <br /> '�1I '���iii'''� BUILDING INSPECTION DIVISION 7f� ,60 7-9/ -M <br /> —��ij`� �� 5155 Silverton Rd NEiii— v" <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, t c s I 1 e - MAhLvc , have authorized <br /> (Property Owner/Print Name) <br /> 6 co—,L Ej A..) N to act as my agent in performing the <br /> (Authorized Representative / Print Name) <br /> p <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: EXPIRE D <br /> 505(0cA \._-.-xr‘r wood �a4 QZ . <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description old' L inn wood 'XL. A 4c, Tax Lot#(s) OQ 3 o 3 f ac C.000303 <br /> PROPERTY OWNER: \ <br /> Printed Name: ;�5 (Y\R L JP ' <br /> Signature: Date: <br /> Address: S 90Q LvMW06,4 Phone: <br /> City, State, Zip cvkA Oe- ' ),3Lit.f, Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: S Co (jv N <br /> Company e: `J c o } (y1A/ J LA S-InA,4 O N V\C <br /> Signature: /42) Date: /c/-I-tom <br /> Address: 1'• .,. 6..„ c7 (f 3 Phone: SUS- 9 3 -S Vo b <br /> City, State, Zip ( l..sI 0C- Cj 73(a) Fax: <br /> E-mail Address SbC.ON5-VO3 Q-W VI , i- <br /> DEQ License# CCB # 1? I (o 8 q <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />