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DocuSign Envelope ID:C9346C42-A43E-427F-9BF8-7D9CD7D8F5D9 g-004-761 <br /> 4�� MARION COUNTY PUBLIC WORKS <br /> ��� BUILDING INSPECTION DIVISION [C E <br /> ue <br /> p` �� 5155 Silverton Rd NE <br /> Salem OR 97305 s JUN 22 2018 <br /> (503) 588-5147 Fax(503) 588-7948 I G <br /> http://www.co.marion.or.us/PWBuildingInspection MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Richard L Bergerson I, g ,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 /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 081E01B 00900 / 20900 Grade Rd Tax Lot#(s)R39520 <br /> PROPERTY OWNER: <br /> Printed Nagus R rd L Bergerson <br /> Signatute( 4,„ Date:Jun-21-2018 I 9:36 PM PDT <br /> 201133BGzr°�ai a Rd <br /> Address: Phone: <br /> City, State,Zip Silverton, OR 97381 Fax: <br /> E-mail Address richardbergerson@gmail.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Oregon Sew r&& . LC <br /> Signature: ,% Date: <br /> Address: PO =. 12:2 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\SEPTICVS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />