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T- • <br /> MARION COUNTY PUBLIC WORKS <br /> 4141140414,41p. BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NESalem OR 973051-ECEIVED <br /> (503) 588-5147 Fax (503) 588-7948 ?t-- <br /> http://www.co.marion.or.us/PW/BuildingInspectio9n 1"� 2019 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> • <br /> �;l�� ()N CC�t�N <br /> 6UtLD€ C t SPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> • I, (Ark e`& 'Robe. , have authorized <br /> (Prperty Owner/Print Name) <br /> ij d G�,\ (Zo f Q, to act as my agent in performing the <br /> (Authorizdd 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 /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description (014$t MO s ✓4((el (_P Tax Lot#(s) <br /> PROPERTY OWNER: 'n <br /> Printed Name: --1a(•� et PO e N icot e S L LC_ A tit, ei-& Pas <br /> Signature: Date: g/lwlc7 <br /> Address: (a/y-g• Eta ns VVetI(!,7 Lae-, Phone: So3 • cl I -153 <br /> City, State, Zip SA icek&A ca(Z q 7 3 6 I Fax: Spa •€.13-S S40 <br /> E-mail Address Q- S ik Jet-fit. I t S-e Co/ • Ca Al <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: � a h 1245c <br /> Company Name: '(mil. 20 sc., C v Cos - ' <br /> Signature: Date: / l <br /> Address: 1 t K 5.36 Phone: rj0� �32 �0 <br /> City, State, Zip )I l v erlO f .173 5 f Fax: 5 03 g73 7779 <br /> E-mail Address b f yet <br /> (57) /nct X 1 rn u r? s A , Com <br /> DEQ License# CCB # a 6 .),_q 3 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />