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MARION COUNTY PUBLIC WORKS [ 93-'OO l g <br /> „ BUILDING INSPECTION DIVISION D E IC E V E <br /> sj " 5155 Silverton Rd NE <br /> lR <br /> (503) 588-5147 Saem O Fax97305(503) 588-7948 SEP 27 2023 <br /> http://www.co.marion.or.us/PW/BuildingInspection MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1 4/1/1C,0il � r have authorized <br /> (Property Owner/Print Name) <br /> f€rr yerm to act as my agent in performing the <br /> J (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 IDENTIFIC/ATION: • <br /> / OQ 3 #4 c. -€ e. . at 7 7 ?6 ! <br /> Property Situs or Street Address . • <br /> • <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: 4/414-6,A1 / 1 4k et J <br /> • <br /> Signature: �- Date: - /f <br /> Address: jc 0 g 14,4,y„s i ,//e Phone: 005 $'18 Lip/ <br /> City, State, Zip Si�„��-/a,,, Grit ' 7 3, ( Fax: <br /> E-mail Address 4k,fi / i/ (( �''-1 %L.. e/''- <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: ! C'1(, UIG <br /> . • Company Name: ®A Q`9 1 er1 t(� , b nc <br /> J -' 2 <br /> Signature: �� c q/i✓`� Date: f I�12013 <br /> Address: kept 5 Galin St • Phone: <br /> City, State, Zip ¶«as, (Je-- a7336 Fax: 6513 ' (923 ' 253 , • <br /> E-mail Address 3436 . U(V)eP de b <br /> cal <br /> DEQ License# ?j ) \ CCB # 1�2_-1 2./ <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />