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{ L. CLEAVE <br /> • <br /> D <br /> ` IYiARIQN COUNTY.PUBLIC WORKS <br /> "� "'iu.�• BUILDING INSPECTION DIVISION AUG 2 4 2022 J <br /> �. �� 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> milimi (503)588-5147 Fax(503):588-7g48, BUILDING INSPECTION <br /> 111111.1111. <br /> http://www.co.marion.orms/PWlBuiidiugInspectioa <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1 LARRY EISELE. have authorized <br /> (Property Owner/Print Name). <br /> OWEN CONSTRUCTION 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 /> 310 Boulder St N Detroit OR;97342 <br /> Property Situsor Street Address <br /> And described in the records of MARION County as: <br /> Legal Description HAMMONDADDITION BLOCK 3 LOT 5 Tax Lot#(s) 105E01BC07900 <br /> PROPERTY OWNER: <br /> Printed.Name: LARRY G EISELEc ,f. <br /> Signature. � G- =kc Date: 0l22/2022 <br /> (I Phone: 503-7304193 <br /> Addressi 2313tiKI <br /> :PENS"ST NE t <br /> City,State,Zip KEIZER OR 97303 Pax: <br /> E-mail Address. <br /> AUTHORIZED.REPRESENTATIVE: <br /> Printed Name:, <br /> p rt C �y <br /> Company Name: 9,1,ue tik t Ali tt<1-r ccCI 1 d rt <br /> Date: e(t ' 2Dz Z <br /> f <br /> Signature: <br /> Address: : `0. . .bX 21 t 5-0 Phone: .503 9 c{q /8. k, <br /> City,State,Zip Kt!►..C C.Ir 0 r 9'7.b 7 Fax <br /> Dre. ,� 0i OCASt't+iravCS� rt-9C�l`srl1 C.. CC --t <br /> E-mail..Address •. <br /> I)EQ.Liccnse# 3gsr"-? <br /> 41 CCB# i6 S 6 I <br /> GAFORA1SSEATIOS•07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 4, <br /> SEPTIC. <br />