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An t,•, MARION COUNTY PUBLIC WORKS 01)4-6,60 I Epp <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE RECEIVED - <br /> - Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MAR 04 208 <br /> http://wvvvv.co.marion.or.us/PW/BuildingInspection <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, A c.ria IR/j (;&-7A iv ld y5 LL ,have authorized <br /> roperty�wner/Print Name) <br /> p ��/ r-, ,/� 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 Qriality or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. - <br /> PROPERTY IDENTIFICATION: <br /> 1 v t 64° I Jn— ('/ <br /> Property titus or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: • <br /> Printed Name: (,S A <br /> • Signature: Date: 2-- <br /> Address: 63,7 1/0 1 Phone:5 - 9 S 6/ <br /> City, State, Zip ( 7g q 6/ o 6.), 0 2 Q 2, 3 Fax: <br /> E-mail Address j,Lc,/, <br /> AUTHORLZEDI 'REPRESENTATIVE: <br /> Printed Name: V" k 1—L 1 <br /> Company N e: <br /> Signature: • Date: <br /> Address:p 6 y_k // U / .Phone: <br /> City, State, Zip LZA Q1 n/v /1 1 6 9 ) S Fax: <br /> E-mail Address V v L U A/0 A h/ A "y r92._ YA Ho U, <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\S-07 Audi to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />