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Obas <br /> MARION COUNTY PUBLIC WORKSRECRIVEn <br /> BUILDING INSPECTION DIVISION MAR 2 8 2010 <br /> %`" �� 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 llUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildinaInsnection <br /> 1 <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, <br /> -11.41/1S GR-gEER ,have authorized <br /> (Property Owner/Print Name) <br /> Otoe_J ti. Lb, 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 /> ( c,g& ATTLECREEK— '.I) SE , SA-LEA De q7311 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 2 a Lig Ac i ES Tax Lot#(s) 3W2—Lib 03900 <br /> PROPERTY OWNER: �► <br /> Printed Name: I'1�AV i j C,--)41245a. <br /> Signature`-41 Date: 3'2-3"/ <br /> Address: 5061 L4iVCY `RD SE Phone: '3O 30 1 3&1 <br /> City, State, Zip ( L.(U&la) U� 1 Z Fax: D0 ' 50q - 3' <br /> ---r--94}v <br /> E-mail Address (s @ Et>el W h-Mi2f /V ittUC.t L • Cam <br /> AUTHORIZED REPRESENTATIVE: ji <br /> Printed Name: <br /> Company Name: . (-9F l" . ( � r'\icE (!.. �... <br /> Signature: _ _ <br /> Date: s' <br /> Address: g leo"' vitro ,or OVe5? Phone: •--a? 4/9 ✓ <br /> City, State,Zip Fax: <br /> E-mail Address )re-oto 10.)r`�s� ,.a.��rtiC ®a`° i'c— (.5 1'4 <br /> DEQ License# ; re 1p/ CCB# ii5, / <br /> G,\FORMS\SEPTIC Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />