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���� MARION COUNTY PUBLIC WORKS <br /> .,1I i,,'"� BUILDING INSPECTION DIVISION <br /> ��i � 5155 Silverton Rd NE /K-00E/Z9 � ` <br /> ' T - Salem OR 97305 U I -� <br /> (503) 588-5147 Fax(503) 588-7948 n <br /> http://www.co.marion.or.us/PWBuildingInspection- OCT 24 2018 --' <br /> MARION COUNY6 <br /> BUILDING INSPECTION' <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, E6 Gó24j4/7itce / ,have authorized <br /> (Property Owner/131' t Name) <br /> 3 Cp6fl'1)Ct io .3{'s,.)c,, 04 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 /> 2.101 12-60i ns I l SC <br /> Property Situs or Street Address <br /> p <br /> And described in the records of MARION County as: <br /> Legal Description _ Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: R-776r 6 N <br /> le-. /Q/ <br /> Signature: " (� Date: / --...? -7, - <br /> - �-/� <br /> Address.6.3 S. /% / s,ke,_ Phone:16 --S(o ;Z'- .5 - <br /> / � � �7�/ -- Fax: ` <br /> City, State, Zip f O ----- - <br /> E-mail Address • <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: JQJS AVAlftt di <br /> Company Name: 5A Co \r U(J <br /> Signature: .1\;\ .40 Date: I 0- 23 `t <br /> Address: 1 0 {-{Orvy S+ SO Phone: q1 1 - 1 -3 sol <br /> City, State, Zip , ",1 deirt 5y) 6tft ail 3S'2' Fax: . <br /> E-mail Address 11 (--6 ?tl'(O i s u MAI 11C t C1) <br /> DEQ License # 3ci Lo` CCB# I(91 9C 9 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />