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„, MARION COUNTY_PUBLIC WORKS <br /> 4I <br /> BUILDING INSPECTION`DIVISION <br /> „ =s , ---— • 5155 Silverton Rd NE <br /> Sal <br /> em <br /> e m OR97 305 <br /> (S03)588 5147 Fax(503)588-7948 <br /> littpillwww.e&niarion.or.us/PW/BiiildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, <br /> Gl.v�... have authorized <br /> Property Owner/Print Name) <br /> (Authorized Representative/.Print Name)` to act as my agent in performing the <br /> activities necessaly to obtain site evaluations,permits,:and other onsite wastewater treatment <br /> services provided by the Department'of Environmental Quality or County Agent on the proper rogram <br /> described`'below'in accordance-with OAR chapter`' 40 division 071. ty <br /> PROPERTY'IDENTIFICATION: <br /> ram. gE ' - <br /> Prop.,.., L31Lua ur atreet Haaress <br /> And described in the records o -MARION County as:.. <br /> Legal Description ;, <br /> '`” Tax Lot:#(s) <br /> PROPERTY OWNER:. <br /> Printed Name:: '(Y� <br /> Signature <br /> Date:.__________) ` 3 0 -- <br /> aoDe3. <br /> Address:/ 5 ,�. by .� <br /> Phone <br /> City, State,Z2p <br /> ---- ? .., 9 ?3 Oc Fax: <br /> E-mail Address ,16 ti i. , <br /> AUT.IIORIZED R:EPRESENTATI'V'E : <br /> Printed Name: VJ_ i, .- <br /> Company Name' } <br /> Signature:, <br /> Address • i. ! <br /> Date: <br /> Phone:___________503 `Y /_ <br /> City, State,Zip � �` �, <br /> ' -,I r r-- 7.36 7 <br /> Fax: <br /> Address i`e u c� <br /> ---------- -- <br /> E-mail d______ S '.= y-____ _______ CCB# ,Gi <br /> G:IFORMSVSEPTIC\S-07 Auth to Apply,doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC <br /> 4 <br />