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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE ��U`l� <br /> Salem OR 97305 O-3 <br /> (503) 588-5147 Fax(503) 588-7948 n <br /> w <br /> ww.co.marion.or.us/PW/BuildingInsnectio <br /> SEP 01 2023 <br /> IN COUNTY <br /> NOTICE AUTHORIZING REPRESENT• i'` NO INSPECTION <br /> I, ATt-cP Q-C W 2 ,have authorized <br /> (Property Owner/Print Name) <br /> Cc)-(PiASS LoNs tWcCtoa "UGC to act as my agent in performing the <br /> (Authorized 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 /> qZ- NQ,W 4z SALE AA. C) — 9731 <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 /> Printed Name: })t i-J k <br /> i py D Signature: Date: U I 2,y1 Z3 <br /> Address: 12 c A) cT V,-1-1 CZ Phont j(73, 0511 0 — -) <br /> City, State, Zip 1Pcl..fc,i.&. 02 Fax: <br /> E-mail Address * M. e.7'7'e. ("J-4(AkL_,Co'- <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: .lcss4- <br /> Company Name: SS 6,0,4)A-tr�c.t w- i LLC—. <br /> Signatu . _Date: U bzs-- Z 3 <br /> Address: O. hoc y (e7, Phone( b3) C7a'3S5-c, <br /> City, State, ZipR.-U/v4S V,•\l e_ 32 Fax:OCL. Ql-1 S' <br /> h'E-mailR <br /> Address COr& y5 C-CVL C- C-dwStV•VG--tower <br /> DEQ License# 3l 2(o'4 CCB # 2,0CD S 2`{ <br /> G:\FORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />