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II 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 <br /> www.co.mation.or.us/PW/BuildingInstoection <br /> NOTICE AUTHO D G REPRESENTATIVE <br /> 1, Dani S have aut.horized <br /> (Property Owner/Print Nagle) - ev.,466 <br /> 1.3enne4 SeY1/1 korfre to'aCi as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits,and other onsite wastewater treatmeneyrogram <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 /> -7&0 vran4Ii j <br /> inioAve SCofiS Mi I og -7 375 ; <br /> Property Situs or Street Address. <br /> And described in the records of MARION County as: <br /> • Legal.Description I Tax Lot#(s) 00'500 <br /> PROPERTY G'WNER: <br /> Prin tedName: Th.n1ei IA/i flcxxy <br /> Signature:- Date: "7--7-262A <br /> Address: 7(o0 e-rrrInd Viet,0 APC Phone: <br /> City, State,Zip acils NA1 ILs q 7375 Fax <br /> E-mail Address <br /> AUHORIZED REPRESENTATIVE: <br /> hinted Name: CharliC nntrf4 <br /> Company Name:7)e,noel+ acapl-ie_ xifiOe LLL <br /> Signature: Date: 1—-7-2e)z.3 <br /> Address: ?() r" ox 551 ; Phone 6,n3--S37-11q6Z <br /> City, State,Zip RAW a OR C:1-703S- Fax: <br /> E-mail Address bC(111C11-S-e?+1C, }11ter. <br /> DEQ License# 4-0 ' CCB# 21410‘ 3*j <br /> GAFORPAS\SEPTIC\Application Packets\S.07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />