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r <br /> MARION COUNTY PUBLIC WORKS <br /> lir BUILDING INSPECTION DIVISION <br /> )' 5155 Silverton Rd NE <br /> :�.�v,�,.• mu. Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Margaret J Kingman ,have authorized <br /> (Property Owner/Print Name) <br /> Flow Line Construction LLC 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 /> 7808 Champoeg Rd NE, Saint Paul, Oregon <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: °LaWO 2.O00 i 2-Oct <br /> Legal Description see attached Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: Margaret J_Kingman <br /> Signature: J Date: 7/28/2022 <br /> Address: 7808 Champoeg Rd NE Phone:503-550-5748 <br /> City, State,Zip Saint Paul, OR 97137 Fax: <br /> E-mail Addresswildwood@stpaultel.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: /VO(au, !1 JC l Z r Company Name: one' "�I v C 0.1 &in/cd MM Li-C.-- <br /> Signature: Date: -Z- 2 <br /> Address: i i2OS S4g4_'- S4- Phone: S ° 3 &rT/ ' '13O7 <br /> 2 <br /> City, State,Zip SA�GM 0 Q , q?J Fax: <br /> E-mail Address C o Sl`rvc.4( . v 11wc.- ctJ r Co,vk <br /> DEQ License# Scicl 7 cr CCB # 2-3q 41°l Z <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />