Laserfiche WebLink
���� MARION COUNTY PUBLIC WORKS <br /> '''� "" BUILDING INSPECTION DIVISION 0/-0 6 9dO P <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 • <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.orms/PWBuilding,Inspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I Ae-rot have authorized <br /> n� A (r �� (Prope Owner/Print Name) • <br /> At ex a I L (Me 1+e H Okikk 4201114 f C6 I bL5 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 /> g,a.S won --o VS tt5E-LKI K °R. Ss <br /> Property Situs or Street Address . <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> - PROPERTY OWNER: <br /> Printed Name: A L\C)% 1SCP\ <br /> Signature: Date: sl- 7 - ao <br /> 9A <br /> Address: ...s%r,Y. \O`D- -5 6 ‘c l 'LK\ Phone: 91 \ •- 3 )5 - \ 1 k 3 <br /> City, State, Zip L- (c)cA S O`Z g 35g Fax: <br /> E-nail Address A.S <br /> AUTHORIZED R <br /> EPRESEN/TATIVE: <br /> Printed Name: A lax 1 v '�/O <br /> Company N e: 2 Herne. /e cJe ( � <br /> Signature: Date: ? / / <br /> Address:coa in (.1/43 fd Sf I9/c Phone: q)(439 510? <br /> City, State, Zip ill( t ly ok 9736 0 Fax: <br /> E-mail Address rt..)2_Eke_(9( &V-01 Lt. QQ"V- <br /> DEQ License# • rt..) <br /> CCB# ?D `� <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />