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t��� MARION COUNTY PUBLIC WORKS <br /> oil ������"�' BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 • <br /> 111111/ (503) 588-5147 Fax(503)588-7948 <br /> http:/iwww.co.marion.onus/PW/BuildingInspection <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> • <br /> I, . tiv-A4eie„ have authorized <br /> (Property Owner/Print Name) <br /> L.. pVm.- W s-T-S ,C..0 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// (_ 'r / 04 d 93E C <br /> Property Situs or Street Address . <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) 03 Go U 0 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: ,Cu66:27- 6110 � <br /> • <br /> Signature: j 6� Date: 3-3/— Z / <br /> Address: �3�8.2 R.u.'4-0 4y - c -t Phone: a.17- ,S"SZ -. Z.9 Do' <br /> City, State,Zip Fax: <br /> E-mail Address <br /> • <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: L14y 1 <br /> Company N. CeCsfd/lr vNsi, /tJC <br /> Signa : , , Date: 3 s/ 2 a <br /> r � t. � - <br /> Addr:ss: . ft� "?0,3c 00y ‘ Phone: <br /> City, .tate ip , . 4-71/y / 0 ie. >73.2- / Fax: <br /> E-mail Address L•,/) U/vsr72 e (cc1r c,Is j, <br /> DEQ License# CCB# 97/1 7 <br /> G:IFORMS\SBPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />