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/f— w /O <br /> �'�� MARION COUNTY PUBLIC WORKS <br /> 411I 1j1jiiit'"'V 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/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, C_Ol erno`, Le Co. ,have authorized <br /> (Pr-oserty Owner/Print Name) <br /> Dre.,J 15-e r I 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 /> 57. 33 Re_e_ (tJ &ervaJ S OZ 97 <br /> 02( <br /> Property Sims or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description . 1G 19 3 Tax Lot#(s) 75-2_L Z D D 170° <br /> PROPERTY OWNER: <br /> Printed Nae: o _) CO. <br /> Signature: I%ice ArAl` � Date: <br /> Address: P, 0, Dox 8-I Phone: SOT-3073 7 <br /> City, State,Zip SI. IAS.! 97137 Fax: 563—,3g3-7r7y <br /> E-mail Address g CO(e,t ate, 5eei. ra...— <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Dr w,J 13P <br /> Company Name: Cdt��,,,A„ tp.I (411 <br /> Signature: Date: a (`{ ( F <br /> Address: .d &pc / Phone: <br /> City, State,Zip 5/ „f Ode_ 97/3-7 Fax: <br /> E-mail Address Pre.-' (d('d/e,,,�,_gy p/ rex#4-- <br /> DEQ License# CCB # <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />