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MARION COUNTY PUBLIC WORKS (020�- �b a �a <br /> BUILDING INSPECTION DIVISION LE C. r <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MAR 3 0 2022 L-'2-1 588-5147 Fax(503)588-7948g�i�� <br /> http://www.co.marion.or.us/PW/BuildingInspectionR��i, ����� i COUNTY <br /> CTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, MLU/frii / /-2,7?-7 ,have authorized <br /> (Property Owner/Print Name) <br /> Josh Hansen (Oregon Sewer&Drain LLC) 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 /> 9153 /d 1 5 F 1,yci,ts a±/3Sk <br /> Property Situs fir Street Address <br /> And described in the records of MARION County as: �/1/7"� ��L''''r' �L/2�z <br /> Legal Description 99...C...3 4/`/'"lire 14/' ce Tax Lot#(s) eq•6.62 P1)� 3e.D <br /> _1/G7'l�S a/ /7i5 <br /> PROPERTY OWNER: <br /> Printed Name: Mli qy14 /2/ i 4 ai�/ <br /> Signature's f_— Date: ?A)/2 2 <br /> Address: f 1p 7/ S 7 1/c1 Phone:('S7?) e)? ISO <br /> City,State,Zip 7/ O Q2 ''j?72rFax: <br /> E-mail Address Z'Ji Y/ e ('�� cif S7. kW/— <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> �3 Company Name: <br /> Oregon Sewer& Drain LLC <br /> Signature: Date: „ -zz <br /> Address: PO Box 1? • Phone: 503-874-9414 <br /> City,State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address josh@oregonsewer.com <br /> DEQ License# 38968 CCB# 201683 <br /> G:\FORMS\SEPTICIS-07 A►nh to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />