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MARION COUNTY PUBLIC WORKS <br /> 1 ,. BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE D <br /> Salem OR 97305 <br /> ECEHE -7 <br /> (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection JUN 26 2011 <br /> tics <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 52..nC\1 1� . ��LV P^c— ,have authorized <br /> (PropertrOwner/Print Name) <br /> c , tvvyx 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 /> .vs <br /> ��--rr•.,, �c J <br /> L1 M wood _P2 <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: EN rJ ,`S /"( a t(Z Cf/t( <br /> Signature. Date: Cs2—AD— I�1 <br /> Address: SQ �O 4t-Phone: <br /> City, State,Zip (c4-ta O2- Fax: <br /> E-miil Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: J(OL <br /> Company N e: <br /> Signature: p Date: ZD—&(' <br /> Address: ,C7. P X IV 3 Phone: <br /> City, State, Zip 1\IV.`, De_ 7)49 Fax: <br /> E-mail Address c ( J o3 <br /> DEQ License# CCB# 171 Ceg/ <br /> G:\FORMS\SEPTICNS-07 Audi to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />