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•, ` MARION COUNTY PUBLIC WORKS Iq_v05 ) 1y <br /> BUILDING INSPECTION DIVISION <br /> C�D D�I <br /> 5155 Silverton Rd NE1111111 ,..,, <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 JUL 1 1 2019 <br /> http://www.co.marion.on _us/PW/BuildingInspection MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1 I, - \n IN\A. , have authorized <br /> (Property Owner l print Name <br /> Te.sS g :se�rh! .4t f r d`/ Qiii to act as my agent in performing the <br /> (Authorized Represent the/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 /> 11 Sk,.,t.t\NA\1 E n 1_n. L 5 P r bJ O . VI 3 <br /> Property Situs or Strbet Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> k Printed Name: A . <br /> A • %b A- <br /> kSignature: ;; O ` Date: L • Iq - t°I <br /> u S� <br /> Address: t��� `U1�A��+��L l�Li) Lc\• Phone:CA 1•1 1 1 A a rJ <br /> City, State,Zip CA A.1.111111 Of Fax: <br /> i <br /> etc E-mail Address \ ►S � D U(11�t�71it 0g(1 11� r� YY1 a.\` <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 3 5,5 K... st--,2 i4T q+" <br /> Company Name: 4(7L1ff,, Vic 4_ _ <br /> Signature: Date: 7/014 d — <br /> Address. 300 /044 ild i _ tJ�.—_..— -.-__ Phone:.0 3- 937,2'/ / <br /> City, State, Zip S Qle 4/) O1 j 773/7 Fax:5 - 515- <br /> E-mail Address r._... a c -/ bi tirq;11 �3$i q l• Co m <br /> DEQ License#_ 313Z3 CCB # 50/7/ <br /> C:FORMS\SEPTICIS-P7 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />