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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> =7=7 5155 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, C_en�- tC aK 4-10-,a^ , 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 /> /L 6c.€ E %J i C w Lh S S At.CI► 00, `t 73 6 2, <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Pic. 3 f .r,riots A_Ar 20 i r--ozrfax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: m�E',.c uc>M es, 1^c <br /> Signature: = Date: 2/245/i y <br /> Address: 362S lf_s.-Sk(Pt.irt Ls-e.,/ E Phone: S 62 — -23 do <br /> City,State,Zip C4 vg g'7Z/7 Fax: X62-3 7) -V)2 <br /> E-mail Address 1 €'q <<Avp"AKcior>ko-s.c . c o ,h <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Josh Hansen <br /> Company Name: Ore n Sewer& Drain C <br /> Signature: _ <br /> Date: 3-26—(ci <br /> Address: P 1282 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:IFORMS1SEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />