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2' ' ex/665pg.A4-r <br /> MARION COUNTY PUBLIC WORKS <br /> 1ii1 1 '" BUILDING INSPECTION DIVISION <br /> =1~%�`r, 555 Court St.NE Room 2260/PO Box 14500 E <br /> Salem OR 97309-5036 D <br /> (503) 588-5147 Fax(503) 588-7948 MAR 01 Z024 <br /> U ryE <br /> http://publieworks.co.marion.or.us/building,/ f ARION <br /> SUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Flodrya, s.o"same ,have authorized <br /> ) <br /> �tll (Property Owner/Print Name `lo alas!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 /> laser Abiqua Onm RA Sllvarlor.OR 97381 tinitod Status <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 0 ( 1 E y Tax Lot#(s) ®O S 0'D <br /> PROPERTY OWNER: <br /> Printed Name: Rod"ey s�t,aana� <br /> Signature: ` I Date: "Yeti- -- <br /> Address: Phone: soa,8�3�B3e <br /> City, State,Zip s OR.evoBt Fax: <br /> E-mail Address WI®31a�a-a=s®gma==-�om <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: r DD r_ Q <br /> Company Name:-oW t')6 T 2 E- C <br /> Signature: _ U Date: c (28 ( <br /> Address: 6 771 P i F .o. r Phone: S-03--7?/--AS"T I ' <br /> City, State,Zip A a N dt (,Lai 9 75L. Fax: <br /> E-mail Address 0_ c <br /> DEQ License# ca,7 it CCB# ?2_tpfs— <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/07 <br /> SEPTIC 4 <br />