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���. MARION COUNTY PUBLIC WORKS ��Z� <br /> '��I "'7" BUILDING INSPECTION DIVISION 7f� -60 4n. v" -1 te- <br /> ��ij`--� `� 5155 Silverton Rd NE <br /> lot 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, ¶ ecuc.S I i$ eh - mAhLv, , have authorized <br /> (PropertyOwner/Print Name) <br /> 6 cr5LL B AJ �/ to act as my agent in performing the <br /> (Authorized Representtive/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: EXP I RED <br /> 50So O . <br /> . <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description' L iru-. wood jag• �,A IF, Tax Lot#(s) OP 303 f au Co0o.303 <br /> PROPERTY OWNER: \ ' <br /> Printed Name: ;‘,5 M R rLJ/" <br /> Signature: Date: <br /> Address: S.QS LvM1,. 04d Phone: <br /> City, State, Zip (c De- '7),3 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: S Co ()v N I <br /> Company e: 5 uo �j S-cu c,-.6 N kr\c • <br /> Signature: ,./ Date: /045-/--t <br /> Address: P. .. 1 7,,i_ q Y3 Phone: 51/3' 9 3 —S Vo b <br /> City, State, Zip (V\X. C Jr O2-- 9-73(a) Fax: <br /> � v s <br /> E-mail Address bC_ c k)- I3 (L VI C41l"— <br /> DEQ License# CCB #_ I7 I (o ov kl <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />