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MARION COUNTY PUBLIC WORKS tX la\ <br /> BUILDING INSPECTION DIVISION (� (� J7 <br /> 5155 Sllverton Rd NE D LS C{ 0 11 { <br /> ini <br /> Salem OR 07305 <br /> (503)588-5147 F*2(503)588-7948 FEB 08 2023 Lo , <br /> http://www.comarlomor.ms1PW/Buildlitglaspection <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, r C kU.r a % rook. ,have authorized <br /> (Property Owner/Print Name) <br /> to act as my agent in performing the <br /> (Authorized'Representative/Print Name) <br /> activities necessary to obtain site evaluations,permits,and other oasito wastewater treatment program <br /> services provided by the Department of Environmental Quality or County Agent on the prxipcity <br /> described below in accordance with OAR chapter 340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> urtw'tk r [ar h ,r Or C7 <br /> Property Situs or Street.Address <br /> And described in the records of MARION County as: <br /> Legal Description C•i C{o eZeky Tax Lot li(s)ACCOtk) t 140. dd <br /> PROPERTY OWNER: <br /> Printed Name: \ r Gc k c <br /> Sivature: Date: <br /> Address: 6 tf 7 1.1 r�,•ya�� LCx1ng Plum+ N.03- 7 i— a� <br /> City.State,Zip`TtA(I r i_J t". S71'1 2_ Fax:E-mail Address r I C k asr, t C_ <br /> r�T <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name:__ ,Nt- p• <br /> Company /1"*. e./ <br /> Sgnatun. _ _ Dim: \t a1/4-4'0— <br /> Address: PO fi ' ,,`�! Phone: <br /> City.Star^,Zip T(//,:n e.A, 04: (r' l L'_ Fax: • <br /> E --mull Address ti-H- r t'bo;li IV? 76 ,deep,--1 <br /> DEQ License a .3((II CCB u "2,`i; <br /> ti klUtitri'St71105.0 Mtn b Apply.tke <br /> MC-CT Rae 03t1L <br /> SEPM 4 <br />