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k MARION COUNTY PUBLIC WORKS <br /> '�� BUILDING INSPECTION DIVISION p' <br /> - _—�%"f►�� 5155 Silverton Rd NE r —��C E��[I! MST <br /> � <br /> Salem OR 97305 <br /> : <br /> (503)588-5147 Fax(503)588-7948 ,I� <br /> http://www.co.marion.or.us/PW/BuildingInspection FEB 0 4 2019 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> t, ahn 0 -e ,have authorized <br /> �^ <br /> (Property Owner/Print Name) <br /> to act as my agent in performing the <br /> (Authorized Representative/ 'nt 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 /> 7 � HDer 6+; S aem, OR Q13t7 <br /> Property Situ or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: 1` )Un nous <br /> y '4 l <br /> Signature: ��./yl��� ��c Date: 125/i <br /> Address: C� Phone: 503_,,,9`f S' ) <br /> City, State,Zip o 1evyi ct 7 I -7 Fax: WA <br /> E-mail Address N/A <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: OZ--W? •I <br /> Company? me: `i . i•► � <br /> Signatur0, Date: <br /> AddressOPhone: <br /> City, State,Zip BUY 1(\9 oct._ ein:b.ak a Fax: _ — l - J <br /> E-mail Address3 ( \ .Q)(L '((Air\ <br /> DEQ License# 2\0 %- CCB# l\LASS <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />