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MARION COUNTY Y PUBLIC WORKS <br /> ail • k' Nu; `- C.i.E[IYE <br /> BUILDING INSPECTION DIVISION <br /> ""' 5155 + iiverton Rd NE <br /> Salem OR 97305 MAR 3 0 2021 <br /> (503)58&5147 Fax (. 3)588-7948 <br /> www.co.marion.or.us/PW/Buildin2Insnection`/Buildin2Insnection MARION COUNTY <br /> ILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> �I V , have authorized <br /> (Property Owner P it Name) <br /> cr-••/2 —__ to act as my agent in performing the <br /> (Aut orized Representative/Print Name:) <br /> etivhies 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 IDENTl lt_`•i I ION: <br /> 35.E - 5f- SE, h otA5 .0 1 7...3.5 <br /> Prc'pert S1Itt;. ;i Siieel :Address <br /> And described in the records of MARIOO'U County as: 3<3Z;9/ 1 �"e.;/ic.i s 5E lt"c"r fi <br /> Legal Description re, }{j lk.tz<,..:z sc. B ,-' 4# ._.Tax l:_at#(s)ve 3.7 L(`t I fx- <br /> e9.5) r?e.ry <br /> 'OPERIN OWN ER: <br /> Printed Rime: .� j , -T..} <br /> Signature; Date ZL <br /> Address: � J ..C�..o 0 v ._ �_.phone 5 3_._._... 8 -a 53) ( e/ix <br /> City, State,Zip. .2/,V frm d C _ ` `7 a2 L_ Fax:E-mail Address.._._��` _ : e.[1.1'a l 5_. /._8._ ...I_ "� 1«..r.`1 • cl��'1✓�. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: ..: ,. ,. , :? r %.! .. LC. <br /> Date <br /> Address: __ 2_0 f 7c,r? _>r <br /> It}`, State,ilp�/"s/�. / ,, ?! f1=._.* 5 .. .._.__.—.._ Fax: <br /> E-mail Address ( / /I s. ,✓'. r! r/ c, <br /> I)LQ t.icense.# 3c 2 GCB <br /> G,,,FORMS'_tit=;C'TR_s=tippllegrioci I':3+ ei,•S-ti71lut}r to Apialj:d,rt <br /> MCS-07 Rev03/10 <br /> SEPTIC 4 <br />