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MARION COUNTY PUBLIC WORKS <br /> 1 BUILDING INSPECTION DIVISION // `� <br /> 5155 Silverton Rd NE LTJ `'/ 1 <br /> Salem OR 97305 _FA <br /> (503) 588-5147 Fax(503) 588-7948 MAY 02 2016 '.-..J <br /> http://www.co.marion.or.us/PW/BuildingInspection . z .-. , <br /> COUNTYCJ.ti <br /> fl A tl.. N COUNTY <br /> BUILDING INSPECTION <br /> NOTICEIIAUTHORIZING REPRESENTATIVE <br /> I, &a.‘,-- (? InA ,have authorized <br /> (Property Owner/Print Name) <br /> kto 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�IDENT�ION: <br /> Q <br /> 1 .��011 ti ' 1 " 4- Zor" �c <br /> 24 y Pxoperty Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description coZ. — i 2 ne &e.:\ /%,,,,,, I.c Tax Lot#(s) Ci13u O� Pc o o(2o l <br /> PROPERTY OWNER: 11 <br /> Printed Name: Sew— ( ,,,,i <br /> *Signature: Date: <br /> Address: I-1-m q a,ue lc )J Phone: -ceal <br /> City, State, Zip 1-e.2e✓ O VC q1 30 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: letvtAk5 &A <br /> Company <br /> j2-' Date: yiiie..)(s <br /> Address: 60,g 5-044 Phone: 503 -74(3— EY!) <br /> City, State,Zip—1 t,.v OVL 91 3q 2 Fax: 7f 3— L2 3' <br /> E-mail Address <br /> DEQ License# 7J(q I % CCB # J� I <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />