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� MARION COUNTY PUBLIC WORKS <br /> ,�ii1j ��� 't"'ip BUILDING INSPECTION DIVISION <br /> 9 5155 Silverton Rd NE <br /> 1111111 Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> httpwwww.co.marion.onus/PW/BuildingInspection • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> • <br /> I, '?.0 -T ,S j1/l "` e have authorized <br /> (Property Owner/Print Name) <br /> L %J. (,v --ws--r' —D,.( 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 /> • <br /> PROPERTY IDENTIFICATION: ' • <br /> (o�e2 .Lzoo /?t/� l -s d4 0g3t z�J <br /> Property Situs or Street Address . V <br /> Described in the records of MARION County as:' <br /> Legal Description Tax Lot#(s) 036, 0 0 • <br /> Subdivision,Lot and Block <br /> • <br /> PROPERTY OWNER: <br /> Printed Name: A�c,27— C511 / 4_ <br /> Signature: j 6 Date: 3 73/— L / • <br /> Address:_,3 ,SZ ,�v -0 Arc- �rfrE Phone: 22.J 7- ,3'S2 -. Z 9 OS <br /> City, State, Zip Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: #t/& <br /> Company N.le -: c Cecsrem v v ,, /AJC - <br /> Signa .e: I , , Date: 3 .e/ 2 0� <br /> - <br /> Addr;ss: ft� .e5173c 0099 Phone: <br /> City, state . ip , 44-A/y , 0' 97 7_ / Fax: <br /> E-mail Address L,� tees-rac-elt e coafc4sr, dc%s-7 <br /> DEQ License# CCB# 97/7 7 <br /> WORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />