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26 — p°tit <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> ..��%,;-✓," �. 5155 Overton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marlan.or.us/PW/BuildIngInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> a ,have authorized <br /> (Property Owh /PrintName) <br /> Josh Hansen (Oregon Sewer 8 rain LLC) 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 /> Property Sims or Street Address <br /> And described in the records of MARION County as: r <br /> Legal Description -7 ,r '�� � G �j Tax Lot#(s) ( I c`/ <br /> PROPERTY OWNER: <br /> Printed Name: 4.3 CL._. �_ t C <br /> C 20 � <br /> may_....._ <br /> Signature: � t Date: -2 62- <br /> Address: 42S ied Phone: 50 , (it . , 0 <br /> City,State,Zip £, �I —7 3 C 3 Fax: <br /> E-mail Address 44, O4 1 15 cD S-62 Lr''Y'i.4)(1 P S-i-zar.s , e v�✓�' <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore9n r&D in L <br /> f, <br /> Signature: Date: ( <br /> Address: Pox 82 Phone: 503-874-9414 <br /> City,State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address Josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 <br /> c:ORMS SEPT1C\S.07 Auth to nppiy.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />