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ife ,,,, MARION COUNTY PUBLIC WORKS <br /> ''l.` <br /> �� BUILDING INSPECTION DIVISION <br /> ,,.�ij�`��`�� 5155 Silverton Rd NE <br /> Salem OR 97305 EXPIRED <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, ,-c c t LC , have authorized <br /> (Property Owner/Print Name) <br /> Katie Ryan to act as my agent in performing the <br /> (Authorized Representative/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 /> 2 S 0 ---rro v. t- 5-4- ic2e(- <br /> Property Situs or Street Address <br /> 1 And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed N: -• k,i 1 Q (.4,c_, <br /> Signature: ,�,•,�,A_ `t c.-4 / .QG..r ►-9 A, Date: i <br /> l tat )a O2 1 <br /> Address: p i s' v,•';ti, S`r C' Phone: sQ 3 6`P— ,,,)y J e <br /> City, State,Zip ctk st•E0,1 EL,,,-, qv-3 al- Fax: 921-"273— )S ci7 <br /> E-mail Address O vl C�;- v►.,ta✓• Q o•e I_ Co vv) <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Katie Ryan <br /> Company Na e: he xc sting <br /> Signature: Date: <br /> Address: PO Box 504 Phone: 503-743-2343 <br /> City, State,Zip Turner, OR 97392 Fax: 503-743-3638 <br /> E-mail Address officeCa�bethelexc.com <br /> DEQ License# 36198 CCB # 44551 <br /> G:\FORMS\SEPnC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />