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�� ��� "1 <br /> I!' MARION COUNTY PUBLIC WORKS <br /> ��� � ���"� BUILDING INSPECTION DIVISION <br /> � 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503) 588-7948 MAR 29 2019 <br /> http://www.co.marion.or.us/PW/Buildin Ins ection MARION COUNTY <br /> p BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Youth With a Mission/Slavic Ministries int. Alex Akimoff Cvehairau omannzed <br /> I, a <br /> (Propeq Owner Print Dame) Z <br /> D��h n s rlrC i19 n k a- 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 /> 6946 Battle Creek Rd. SE Salem, OR 97317 <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: Youth With a Mission/Slavic Ministries Int. Alex Akimoff Chairman <br /> Signature: ".4f Atiliel Date: 01/07/2019 <br /> Address: 6946 Rattle Creek Rd. SE Phone: 503 363 5238 <br /> City, State,Zip Salem, OR 97317 Fax: <br /> E-mail Address alakimoff@gmal.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Dr p 93 Ccill t r <br /> Company Name: C) )e. Covc, ) r L.3 cl-o'C Iry r v‘ e <br /> Signature: t Date: sy/ /9 <br /> Address: P . + 6 y l'it 50 Phone: 703 4-4/4 /e .d <br /> City, State,Zip t€f ? r e7 r Q 7.3O /) Fax: <br /> E-mail Address Pr' e Ow f'A C 5 f-S r"u c I`,o T w c-. . CO M <br /> DEQ License# ,�;'Q,5 C,/ CCB # /6 S B 7 <br /> G:\FORMSISEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />