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2(-1-00 33o PgiA41 <br /> MARION COUNTY PUBLIC WORKS <br /> "" BUILDING INSPECTION DIVISION <br /> 19 <br /> 5155 Silverton Rd NE [) E -© -E - V <br /> mii Salem OR 97305 <br /> •/ (503)588-5147 Fax(503)588-7948 <br /> http /www.co.marion.or.us/PWBuildinglnspection APR 30 2024 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, l'Ol+yt yt E 4-�/wt I ce- eye 9- <br /> Y RLT SdtYilce Ronw, Trttiet. have authorized <br /> Lee- FJe. e� (Property Owner/Print Name) <br /> ' ej E)Ccil.VcCiirvol to act as my agent in performing the <br /> (Authorized Representative/Print Na ) <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 /> 5 611 Pai°,0 -r- / LEI 5E , Texrvte 1' , 0R 173f cZ <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Te ffe v .y ff es (L;z) Tax Lot#(s) <br /> Subdivision, Lot and Block <br /> PROPERTY OWNER: <br /> Printed N 4- <br /> 0 <br /> • �'k►�r� E mice d?oher 14LT 9- ar4 ce. one(' Trusfe-e. <br /> Signature <br /> I Date: <br /> Address: 706 SE R2c.W0oac Cf: <br /> Phone: 503-769- I$YZ- <br /> City,State, Zip Sub(im�-l-y, 0Q g7385 <br /> Fax: <br /> E-mail Address , 1-ohev o� W f i . Co L4'l <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee. 6e-11/Ne1 <br /> Company Name: Be-ke( Fxco `t-- v j <br /> Signature: �J/ <br /> �✓� Date: of h /iv ti <br /> Address: Po &o x 50/4 - 6.77d L tt!� FcQ 5 E Phone: <br /> �3_ ]'�(3•�3 t�3 <br /> City, State,Zip }{'Y1ee, 0 Q 9 731Z_ Fax: <br /> E-mail Addresses ;Ce f pee f P x CO�Yj <br /> DEQ License# 36195 CCB# 5 f <br /> G:\FORMSISEPTICIS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br /> e• <br /> i <br />