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' r <br /> � MARION COUNTY PUBLIC WORKS <br /> un: <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://.www.co.marion.or.us/PWBuildingInspection • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, l ' e _ _' have authorized <br /> (Property Owner/Print Name) <br /> 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 /> • <br /> PROPERTY IDENTIFICATION: <br /> • Property Situs or Street Address . <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: tt'. pLar.,6,0, <br /> Signature: ,O � Date: zit(p� <br /> Address: C.A$V� Phone: <br /> City, State, Zip 'OC Fax: <br /> E-mail Address W-itte.-10 e S1n,- c � <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: 0 ICI a� I(oiyt(d <br /> Company Name: . Qn Ct (01A G 1br <br /> Signature: Date: 6-6 -Z02`- <br /> Address: (4-3 Was t)\ 104 C' S . Phone: S41 - 3?-8-573/ <br /> City, State, Zip 6a I'pwl Q -7(7 Fax: <br /> E-mail Address J.0.,V4abkd ttAciervaioiN. Itc5 f�a�I . (OA <br /> DEQ License# 3q43 CCB# 31 41-15r <br /> GAFORMS\SEPTICIS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 • <br />