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��� MARION COUNTY PUBLIC WORKS &3- a)lal5 <br /> ,� ,��,, .„,,yam BUILDING INSPECTION DIVISION (� <br /> -. 5155 Silverton Rd NE D E C E U V <br /> .1.1 <br /> Salem <br /> OR 97305 <br /> www.eo.ma <br /> (503)588-5 Fax(soa)s gas FEB 0 8 2023 <br /> http:/l rion.o r.us/P W/Building Inspection <br /> U___J) <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING44 REPRESENTATIVE <br /> I, cko r A 4- c a Y�- ,have authorized <br /> (Property Owner IPrint Name} <br /> �A� to uct us 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 U VA ir- A Cy r 0 r cI .7 <br /> Property Situs or Street Address <br /> And described in the records of MARJON County as; <br /> Legal Description R O txf)K ' ' ere,e erky Tax Lot N(s)Aaookra ll[,r, <br /> kct <br /> PROPERTY OWNER: . --`- -- <br /> Printed Name: \ t;.1s.01,,i VI tir Gd r <br /> Signature: ,_4,(7tj...—. Date: k i 7 <br /> Address: 6 /f 7_ ti=' r�art� AS Phoac;_ /fO - 7 k' ?C0d <br /> City,State,Zip--TtA[v....cc 0., ck-73 S2 -_ Fax:- _ _.------ <br /> E-mail Address r 1 C �C�r. 1 t C_ ( ) �y{ v''�A\ \ c + --- <br /> T <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ,)ii\k-- �I. <br /> Company N JC..e.f . :/ I ~r - • <br /> Signiori. Date: `-0 l a --k,l'3/ -- <br /> Address: r0 /3/9( f,.%!{ Phone — <br /> City.State,Zip J('/l'niC/, G'/_ TL J,-:'_ Fax: <br /> E-utarl Addicss r:, ",'%L:-'(:'lley,,,t're yt ,tf,,»t <br /> DEQ License K 116-i'i CCB# I: u J'i <br /> i,-,. its rats-t Agoralloy a <br /> most?Rev nt^r <br /> SEPTIC 4 <br /> I f <br />