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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION (� <br /> 5155 Silverton.Rd NE ® E C E f v <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 MAY 0 5 2021 L_ <br /> http://.www.co.marion.or.us/PWBuildingInspection <br /> ?viARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, L.2-Ltln i C1 L J ky . have authorized <br /> (Property Owner/Print Name) <br /> n,1w 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 Qr'Rlity or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> Cci s'G ' •AJ e /t <br /> Property Situs or Street Address <br /> - Described in the records of MARION County as: <br /> Legal Description Acres -S? Tax Lot#(s) p 6 2 W 33 Sod 0 id 0 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: C \ `2,ediaLthW\vi-fiA Lir <br /> Signature: �,h Y1a <br /> � SS' Y , o IQai1 <br /> Date: 5 15 I i a <br /> Address: f 5G-7 ` Avg /V E Phone:5 5( Lo"1 L' <br /> City, State,Zip ‘e vv` O k G 13 0 5— Fax: <br /> E-nail Address w 4 v ei i i o- a U D D n%mom rn <br /> AUTHORIZED REPRESENTATIVE:�A <br /> V <br /> Printed Name: ct.c. C ' l u,e.,\, <br /> Company Name: /V/A <br /> • <br /> Signature: Date: 6- -2t <br /> Address: \,® 7S ?d /V6- Phone: 5 73`R'l o - 1( Ss-- <br /> City, State,Zip 8,` e t)f 13 R t Fax: kl(\ <br /> E-mail Address 3 Lob nAue,\\-eT' QI&VIat�,cb✓Y. <br /> DEQ License# 41lk CCB# AU/' <br /> G:IFORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />