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MARION COUNTY PUBLIC WORKS <br /> 0I t�,„'' I.� BUILDING INSPECTION DIVISION <br /> u <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, 2��h� �p , have authorized <br /> (Property Owner/ Print Name) <br /> Te'f I).e S cM 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 /> ‘-ies Or? 1:134t4' <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: Sulc,\N o.c\ g\NACk< <br /> Signature: Date: +�,n 3 <br /> Address: ll(o S+' Phone: hi ?47' a`I(1 <br /> City, State, Zip C&e5 OAR C113'110 Fax: <br /> E-mail Address \ O CkAo\A. o\o\ covV\ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> `�T "P.rr IUPLvil" r) <br /> • `I <br /> Company Name: lea N S/a1 t L Le <br /> Signature: • Date: 2[30 <br /> Address: ) '35 teekle 'pLrl note, Phone: 50;3- (>13,iD-asci) <br /> City, State, Zip 24 n on , (?12 q-) `- Fax: 503- 7(a1- 33/o2' <br /> E-mail Address C L St (c-t: e rr <br /> DEQ License# j()11�'j (7 / CCB # <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />