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- 2g-Dos-toll par r <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> l`���� 5155 Silverton Rd NE <br /> Salem OR 97305 • <br /> (503)588-5147 Fax(503) 588-7948 <br /> http:/iwww.co.marion.or.us/PWBuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 5?a e j e.t have authorized <br /> (Property Owner/Print Name) <br /> to act as my agentperforming in erformin 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 /> CZ3S 1, 4ti-' . &e1+ -f c?/ tc. ? 7�� <br /> Property Situs or Street Address - <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name:SA. ivy ,oP9 pc/ <br /> Signature: re--2, - Date: 7, 2'—79' <br /> Address: sZ tali,/ S G C Phone: <br /> City, State, Zip 5,'/v�-en ©fL ? 7 3 yei, Fax: <br /> E-mail Address Co 4 5.47/v cltw S i'Z z6��a 7,Cd- <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: <br /> • <br /> Signature: Date: <br /> Address: Phone: <br /> City, State, Zip Fax: <br /> E-mail Address <br /> DEQ License# • CCB # <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />