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.,,, MARION COUNTY PUBLIC WORKS <br /> ��l ����"� BUILDING INSPECTION DIVISION <br /> u,,. <br /> j -...---di" 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 4( I, 664, S dt3t[ - , have authorized <br /> --�- (Property Owner/ Pri Name_I <br /> je,SS l- ►$e !� Ac i Ce /.J�q+1y to act as my agent in performing the <br /> (Authorized Represen3 ve/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 /> k 3 qt .c) s/a1--f Lit/ S' <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 /> k Printed Nam • w_ SA O- 4e, <br /> kSignature: Date: 6 Z,Z 2(. <br /> tv Address: 3%i (5t)L4107 /J ZA)3 L.Phone: SZj3Y? 7? A' <br /> City, State, Zip /C/,'�16/ oQ. /76.1 Z Fax: `' <br /> `' E-mail Address j l . Jtt3Zt'l le: eneil/� G11 <br /> GG <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ate 5_5 K .. 1q <br /> Company Name: /JGfi'9d vcgi}) J p <br /> Signature: � # Date: 7/00�0 t <br /> Addres . 300 /1' 4!'1'1 iY J Phone:5'0 3- 932-Z'/ol <br /> .,:.y State, Zip ..; 1 Iv i - , :-/0 9 7 <br /> E-mail Address Jr. Qc-"/andrgir1 Q7(3meld. Cem <br /> DEQ License# 31(32.3 C C B # 450/7/ <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03110 <br /> SEPTIC 4 <br />