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1 j I700%,1 MARION COUNTY PUBLIC WORKS <br /> BUILDINt; INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> am <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http: NN 1%V%.co.marion.onus/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Necultz_______ILI - iSeil , have authorized <br /> (Property Owner '1 Print Name) <br /> _ to act as my agent in performing the <br /> (Authorized Representative/ Print Name) <br /> „ict.‘aics 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 belov, in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> 2./2 cr0& a il me Act , t\faNs op_ 73 cE <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 1;, e „, ,/- 5 qi 1 9 6 Tax Lot#(s) 0/,/a is 0.4a)600 <br /> III), , (co.,,,,- .5--,1 A00 03A PieD.4-0020o <br /> PROPERTY OWNER: <br /> Printed Name: NeOir-c1. A.L 13e i I <br /> sIgnarare:P.,k-il / .cc(2. Date: /6 /,:,2 / bC2/ <br /> Address: Vk ,1e'fif1 lc M ‘ Phone: 5?-)3 c73c <br /> City, State, Zip /,i,e45 I 6 r '7'7 358 Fax: <br /> 1 E-mail Address neorytidl erviv, C ekri <br /> AUTHORIZED REPRESENTATIVE: <br /> ---,, • <br /> Printed Name: ,J kr f1tF I V6 /1 1,6i1k(C <br /> Company Name: /1/).,t_c - 0=.-\ -.,,- <br /> Signature: -2•-?- -- '- Date: /1 7 /..2.0.,1 <br /> Address: 1 7 5 5' 3 j.-- / ..-' .12- Phone: 503 - 750 -0.,/. 3 <br /> City, State, Zip ll.M h„--c, 0 k q 7 i 2_3 Fax: <br /> E-mail Address clA.1. Va.--,L,) ...-.LI, <br /> DEQ License # CCB # — <br /> — <br /> Cs -FORMSSEPTICS-07 Auth to Apply doe <br /> MCS-07 Rev 03/10 <br /> SEPTIC @ i - , • C_ -I, <br /> 4 <br />