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04/19/2019 10:58 5037923700 MARTINMILLERNURSERY #2915 P. 002/002 <br /> • <br /> �, MARION COUNTY name WORKS <br /> �,� "'""-,ft BUILDING INSPECTION DTYISION . <br /> 5155 Silverton Rd NE <br /> Salem OR 97305(503)588-5147 Fax(503)588-7948 <br /> http://vvww.co.marion.orms/PW/BuildingInspection • <br /> • <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE' <br /> i, S a,,,x_ ele►-t.be r ,have authorized <br /> (Pro'-rty Owner/Print Name) <br /> , L. . 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 /> _ , ,dr . i 1 E. 6 . -a4 Pt 0.7305-- <br /> operty itus or Street Address • <br /> And described itt the records of MARION County as: <br /> Legal Description Tax Lot#(s} <br /> - PROPERTY OWNER <br /> Printed Name: 514.5a in, ee'wber, <br /> Signature:—; z. J• __Date:, 04- 1' 20`/ ' <br /> Address: 659.z ?.ak.s 14.) NE,. Phone:. 503—81 3 4 4R7 <br /> 02.41-03-'09- <br /> City,State,Zip S x'137 5 Fax: _ . . 87/o <br /> E-mail Address 5±heti 1 tr.gyp 5 s• <br /> AUTHORIZED.REPRESENTATWE: <br /> Printed Name: y` ; �1l . <br /> CompanyN..i.e: t • <br /> Sigoaattiue: //,.. 40=4.141L. T Date: 4/ ' of <br /> Address: r _1 �-, Phone: P --6"%g3 <br /> City,State,Zip 6q P f I� Fax: 503 ` X` 3 70 C) <br /> E-mail Address id ,i,")( �. _ r 4 14 / • .. <br /> • - DEQ License# 14 IA- CCB# -. .— <br /> elPORMSISEPTTC S-07 Ansh sq,App[y.doa <br /> •MCS-07 Rev 03110 4 <br /> SEPTIC <br />