Laserfiche WebLink
R <br /> .dF� `"�� MARION COUNTY PUBLIC.WORKS; <br /> ��arYgt',1 r�� <br /> "1�^�+ BUILDING INSPECTION DIVISION 3—m c,5 <br /> ��'``—i//_.... 5155 Silvertott'Rd.NE B. <br /> Salem OR 97305 FIJI E��L U <br /> (503)588-5147 Fax(503)588-7948 f <br /> * http:Ilwww.eo.marion.or.usfPWBuildingInspection OCT o.l� 2Q23 <br /> iviAhtury COUNTY' <br /> BUILDING INSPECTION <br /> NOTICE'AUTHORIZING REPRESENTATIVE <br /> I, /2C/ < "a ~d ifalikv / (t ,S art,5 7 i1. L have authorized <br /> ` o r/PiFAY Over e rit Name). <br /> D' e't ,,l i f!j, 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 /> 2 a 11 (-r:,li e.. ., (-''� L i T-# 1. ,-)- s- I `rari , O - 7 7SY <br /> Property Situs or Stre Address <br /> And described in the records of MARION County as: <br /> Legal Description 7 c r * [LZ&EnioAo63co Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: kl,1,21 6 an c I. L.L C. <br /> Signature: '2-4--T--t, Date: 9-t S-25 <br /> Address: f6 136,-/ 9 3Lt[ Phone: 5o 3.el 3o- t4t.Z t. <br /> City, State,Zip 5..1 t Old 130 z.. Fax: 503, 5cM Z.143 <br /> E-mail Address r t.la A-\Ac SiiPi P c Q 4-6 a.,n., e1•-1 <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: r' j e r- <br /> Company Name: O t;.,)J e vt0...itte\-51-.r,}c.-Lr Q vt ' --i <br /> Signature: 01- C <br /> L Date: <br /> Address: }t' E I ( Phone: 5O 3 '`9 I ?6 <br /> City, State,Zip 'i z r r Or ? 736 7 Fax <br /> E-mail Address T r ems. ., lazt OE,„,}:.v , ", ct gC. Cc) , C.O <br /> DEQ License# 3 L CCB# " 6 / <br /> WFORMSSEPTIC s-07 Auto to Apply dac <br /> M403-07Rev 03/10 <br /> aeprc 4 <br />