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MARION COUNTY PUBLIC WORKS • <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NESalem OR-97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, J 0 hrt C 1 cvc. C ,,.cI ,have authorized <br /> (Property Owner/Print Name) <br /> L C.? Res.14 a( 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 /> jcp 47ct_ d D NC A� <br /> Property Situs Or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) 0 77 L ! p D oisos <br /> PROPERTY OWNER: <br /> Printed Name: „1"01 C laetI <br /> Signature: Date: ,.c/ l& r Val <br /> - Address: -6 25 60 I Phone: co 3 a rigs <br /> City, State,Zip Sot D „E 4'7 717 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: L e e e/( <br /> Company Name: A,e,4 6714,4,vc„ ®rb <br /> 1 <br /> Signature: `'.-.'/_ e"` F Date: i`7/7-11 <br /> s <br /> Address: 661 Phone:le) ? -7 L,/ 1 o 23 ? <br /> City, State, Zip " .Pn op 9 212-__ Fax: /1,1 <br /> E-mail Address ce 4/1) (O <br /> DEQ License# A) q 6 CCB# LD 91.51 <br /> G:\FORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />