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111.r.MIS. <br /> • <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 SlIverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> I http://www.co.marion.or.us/PW/Buildhiguispection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> ,have authorized <br /> Eto act as my agent in performing the <br /> KrIetrtairi Ppt <br /> (Authorized RePresentative/ t Arne) <br /> activities necessary to obtain site evaltiations,permits,and other onsite wastewater treatment program <br /> services providedby 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 /> 72-3 a i4k101%3 6 > ; tivqt fO( 9736Y <br /> ProperikSitis-Or.Street AddreSs- <br /> And described in the records of MARION County as: <br /> f nt.,,)_Legal Description 6)-3D_ LaD,s3 ix Lot#(s) ,•••••• 11),2_,w6014/60 <br /> PROPERTY OWNER: <br /> Printed Name: (.5 CtsJ i\e1 ciAo\t" <br /> Signature: Date: 7- 6- 2 <br /> Address: XJ L.GS)r4.541 CA() Lir" C) Phone: 563--7/0--'b 7 y,- <br /> CitY,State,Zip g 7 Fax: Ais/14- <br /> E-TnAil Address' COM cavx <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 52036. &on <br /> CompanyNasi, S k)crits./alinc) 41- <br /> Signature: , . Date: 7/16/ix./ <br /> Address: I •go Ukelien-t ark. Phone: 5t.) 51 797( <br /> City,State,Zip ei.e.c j.IaiS1 OR I c1762-49 Fax: <br /> E-mail Address atreP_Scexcauctle....E.041 <br /> DEQ License# 39 71141 ccB# net it 1 <br /> MCS-07 Rev 03/07 <br /> SEP11C 4 <br />