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1 <br /> MARION COUNTY PUBLIC WORKS - 6bLQr0L`\ <br /> ,A1►� ,�,""1` BUILDING INSPECTION DIVISION �� <br /> '' �t 5155 Silverton Rd NE RECEIVED <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 AUG 02 2024 <br /> WWW.Co.marion.or.us/PW/BuildingInspecfion <br /> NOTICI AUTHORIZING REPRESENTATIVE <br /> '✓ l <br /> I, f9,.f8/1f <br /> 4 41ek ,have authorized <br /> (Property Owner/Print Name) <br /> t <br /> ALL I _/4.5e. , - et,c Se&iz - ct ovz.t•-� t to act as my agent in performing the <br /> (Authorized Represen`fativle I Print Name) <br /> activities necessary to obtain site valuations,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 /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description os-zweisece2/300 Tax Lot#(s) .19 3 PROPERTY OWNER: <br /> ,/ <br /> Printed Name: = ;-`- G' / ,, /�,�pA! ,� 02 <br /> Signature `1J Date: j/'• j? <br /> Address: <r,;, �'''o riVZ Phone: I7, "7/79 <br /> City, State,Zi '7 a 97— (7f Fax: <br /> E-mail Address /1 eI ,feo, E <br /> I <br /> AUTHORIZED REPRESENTTITIVE: <br /> Printed Name: jcji#1- l , s '-i <br /> Company Name: LJ w ,„ - 7- i ezC <br /> Signature:. : Date: 7'2Y Zy <br /> Address: 11 ' 12cI Phone: 7rf7'(-f4/lrf'' <br /> City,State,Zip Si lu �.OK. Tat( Fax: <br /> E-mail Address ,cfat-1.p 5 ; er,‘,� <br /> U <br /> DEC?License# %' CCB# ,0jd j�3 <br /> G:�FORMS1SEPTIC'•Application Packets\S-07 Auk to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />