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\"''+a MARION COUNTY PUBLIC WORKS <br /> Atli t,,tt4147 _ BUILDING INSPECTION DIVISION <br /> ` �, v 5155 Silverton Rd NE <br /> ax Salem OR 97305 <br /> (503)588-5147 Fax(503) 588-7948 <br /> www.co.marion.or.us/PWIBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, `1-(-( 22tOO d ,have authorized <br /> ' (Property Owner/Print Name) <br /> ecsms cy.-� �ecleirSoi'l to act as my agent in performing the <br /> (Authorized Repres tative/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 /> PROPE <br /> RTY IDENTIFICATION: <br /> 'le tV l _A 6r :?<, �C S(.iobe,t-\z:j oLQ1 ' S <br /> Property Sites or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description pon} tk 3551 Co Lp Tax Lot#(s)c j W 35 CC SCR <br /> PROPERTY OWNER: <br /> Printed Name: , (1 r f�- ,(:.-_0G-t <br /> Signature: C., LA,\_.L-L . "t--- Date: Sep-20-2021 J 9:37 AM PDT <br /> Address: C) d e.6 kQ. -t t. 1r '-. SE Phone: 6A c / 52e%(4' <br /> State, <br /> City, <br /> , 'it`-' -�,.{v �1'-) ctjaxr <br /> Zipk <br /> ��Lt <br /> E-mail Address r°Ltd(Y ett.0006 %'' L) IA S re o , cn-\iN <br /> ' <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: SA`e u e m sec eysc <br /> Company Name: A. 'Pe A ex s "t(...)JYf..W t..cJ 1v1c. <br /> Signature: ��,,/:-`3.--�z. '` Date: l}- - f <br /> Address:�Q ?c )O o9 Phone: $(:23-(03 3F 3 <br /> City, State,Zip ‘Lets ("I.- 9 73-.3 Fax: <br /> E-mail Address ped ers (\ , t YV\ 1-�.-L1.PY-)a i <br /> DEQ License# 3q 1 (12. - CCB# 2 gz-f S <br /> G.'.I ORMSSSITTICtApplicatiou Packets\S-07 Auth to Apply.duc <br /> I MCS-07 Rev 03/10 <br /> '`SEPTIC 4 <br /> ' . eau � <br /> w <br />