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`�� MARION COUNTY PUBLIC WORKS <br /> ���I 1j��,l�'''' BUILDING INSPECTION DIVISION a: ��3 <br /> _ _ <br /> mii <br /> ;� `� �� 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> D1r-caEI E -\ <br /> (503)588-5147 Fax(503)588-7948 <br /> http://�v�vw.co.marion.or.us/rW/EniIdingInspection NOV <br /> 2 8 523 6 <br /> MARION coUfa►IN <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 'riarl a Lid hisnn ,have authorized <br /> (Property Owner/Print Name) <br /> Ki 9- ' \,J eiCk to act as my agent in performing 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 /> 30%L, Gon-j t;a -9✓ S£ 7 rn.tX1 or 6 -3612 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) ?' OI3 Inl 2 3 Oa SOO <br /> PROPERTY OWNER: <br /> Printed Name: rlCIna Jati 'ISO() <br /> Signature: g, ;�, 4 , 'Yi Date: /(/7O/2) <br /> Address: 210►3 N E KI iex af'IQ l,0a') Phone: 50.5 -G8q - V 8 <br /> City, State,Zip A`b 0 V , Q g_ g7-3z I Fax: <br /> E-mail Address bxf@fdf►ll ConSfrvGiian. orl <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: J<,s1-ei ' vv.dGi <br /> Company Namee: L i C O f(A titY O <br /> Signature: 6'I l de. Date: <br /> Address: (3 1 7 /\,/Y CJ C4'3 )1, /V Phone: co -9 3 .- .1)5-0 <br /> City, State,Zip K�i 7„- fie , 0 9s)71 ci 3 Fax: <br /> E-mail Address U �-e4dra <br /> . k,,lenr 0 K9T a;1 . Colin <br /> DEQ License# 3-7 pp`16 5 CCB # 16 .go k <br /> G_IFORMSISEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br /> is <br />