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MARION COUNTY PUBLIC WORKS 414~b D (-Coc 1I F}-L <br /> BUILDING INSPECTION DIVISION <br /> .� 5155 Silverton Rd NE RECEIVED <br /> Salem OR 97305 JUN 17 2024 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> r��ww.co.rnarion.or.us%PR%/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Keith and Zoe Kersey , have authorized <br /> (Property Owner/Print Name) <br /> Vernon Lacey 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 /> Property Sims or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 23527 Santiam Way SE Tax Lot#(s) 092E17AB01200 <br /> Lyons, OR 97358 <br /> PROPERTY OWNER: <br /> Printed Name: Keith and Zoe Kersey <br /> Signature: Date: 642/21221 f <br /> Address: 17122 Fern Ridge Rd SE _ .Phone:: 503-769-7586 <br /> City, State, Zip Stayton, OR 97383 Fax: <br /> E-mail Address zoe kersey@yahoo . com _ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Vernon Lacey <br /> Company Name: <br /> Signature: ,,,; �., Date: ‘/!0 72.vzy - <br /> Address: 23537 Santiamay SE Phone: 503-999-4810 <br /> City, State,Zip Lyons._ OR 97358 Fax: <br /> E-mail Address yeca130@yahoo . com <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />