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DocuSign Envelope ID:EC7E4C14-B82F-4565-A241-OADCEF5D93AF Q 2 d <br /> MARION COUNTY PUBLIC WORKS <br /> �O �aT S�2. -�yG�-t <br /> BUILDING INSPECTION DIVISION <br /> 5155 Sllverton Rd NE <br /> Salem OR 97305 <br /> 111111 . <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/13uildineInsnection <br /> /� <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> _ A15 ;'_ ; _ ,have authorized <br /> (PPro}perty er/Print Name) <br /> 57-111Z. f 3v1L JEgs P.Dib 6 A-Wc to act as my agent in performing the <br /> (Authorized Rep five/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 /> 54 5o �. r'4 . S. �' , . , ®g- ?73 If) 0- <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> PATSY 3 HUIE <br /> Printed Name: <br /> e--UocuSip�by: <br /> Signature: ( (I Date: 10/1/2018 1 11:21 AM PDT <br /> 971-208-9331 <br /> Address: 565t1�.a9fd S Phone: <br /> �,, Zip Sal97302 em or <br /> Ci State, Fax: No <br /> E-mail Address Boman 5768@yaoo.corn <br /> Printed Name: 17,0twor 6 <br /> Company Name 5T �V I i— 1-�. <br /> Signature: „Aa Date: g• I ) g <br /> Address: 3'795 /i-Y /1 -Phone: 5D 3-5Y0- 761.4. <br /> City,State,ZipC'� �DFax: '03-34 3- 4Z 2 <br /> f�Z,�R. � 3 � <br /> E-mail Address 'CO b 57A-9-6EI I L IE1-Sj Li--C. <br /> DEQ License# CCB# <br /> o:1FORMMSEPr[C1Applicaion r ckeMS-m Au&to Aty aoc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />