Laserfiche WebLink
�' MARION COUNTY PUBLIC WORKS <br /> ��I BUILDING INSPECTION DIVISION -111 <br /> ��t,,EVED <br /> %` �. 5155 Silverton Rd NE ``' <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 JuN 2 �oZ� <br /> http://www.co.marion.or.us/PWBuildingxnspection <br /> O2 L 4 6b <br /> iiii,,,,,,---• <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Eirlril4fluel DI b)-e eh rck , have authorized <br /> (Property Owner/Print Name) <br /> Josh Hansen ( Oregon Sewer& Drain 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 /> O 5 l 02 ,.).„,,d,,,u,..., 1E Ai ' <br /> _ . <br /> Property Sims or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 07 i i-t6GG iloo Tax Lot#(s) l/GU <br /> PROPERTY OWNER: <br /> Printed Name: /M�ar tc.n ( gi b 6 L[iVG k <br /> Signature: e�.J_c..4A.-.. /&.& COM-al Srtrtnar) Date: 6-/a o2q <br /> Address: gSj� Sun►gycJwcJ rid—fjg_ Phone: <br /> City, State,Zip S&(u,,,t r QrZ 4.1 S-- Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Orego r& Drain LC <br /> Signature: Date: 6-f 2.21/ <br /> Address: PO x 1 2 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 /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc . <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />