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MARION COUNTY PUBLIC WORKS <br /> ,id <br /> BUILDING INSPECTION DIVISION <br /> - �11%///` ; 5155 Silverton Rd NE <br /> Iiiijjj <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://ww.w.co.marion.or.uslPWlBuildingInspection. <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1 L David Whitton ,have authorized <br /> —�— p (Property Owner/ nt Name <br /> Ji. 5 G� :5 L rj j z ,kC ;cif 'Q;ii to act as my agent in performing the <br /> (Authorized_Represent ive/Print ame)' <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 /> k 199 Ankeny Hill Rd. SE, Jefferson, OR 97352 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal.Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> k Printed Name: David Whitton <br /> kSignature: Date: 4/25/24 4- <br /> + Address: 199 Ankeny Hill Rd. SE Phone: 503-949-0203 cl <br /> et City, State,Zip Jefferson, OR 97352 Fax: I <br /> or E-mail.Address David @SalemREG.com <br /> AUTHORIZED REPRESENTATIVE <br /> Printed Name: J -e. 55 V. .54- f .. <br /> Company Name: 4tfi' i 7 rq i p <br /> Signature: Date; 7/Bra//6 <br /> Addres .. D Phone:50 3 932-2.0/ <br /> City, State,Zip 5 rtle.4 i pi ?73/7 Fax: co 3 - S??- 2'3O'/ <br /> E-mail Address if. Q C�'1 on Upq;ci l p ki Q 1. Ct3Y i <br /> cJ <br /> DEQ License# 3 (3z3 CCB# 50/7/ <br /> G:\FORMS\SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />