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�'��� MARION COUNTY PUBLIC WORKS <br /> ��I 1j'1j''"` BUILDING INSPECTION DIVISION <br /> ...„,..3.....- -`. .v 5155 Silverton Rd NE / 0d �i9 <br /> Salem OR 97305 <br /> MI (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, fin Cii f4 0-L ) 5 ' i,*A-T ,have authorized <br /> (Property Owner/Print Name) <br /> No it,,uvtal—Li (< Lc._ 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 IDENTIFIICATIO <br /> Yr i?' 1&(1-- L14 <br /> LF(441 Ce/L/ <br /> Property Situs or Street Address <br /> / <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s)%05;tZ3 a) 5.1?C; 0 0 <br /> g2-rbc? <br /> PROPERTY OWNER: Li 30° <br /> Printed Name: <br /> lam'►-ti-T-Z'1-[cam 6-7-L ce-Ae__l <br /> Signature: k � _ Date: `-i / //, <br /> Address: 27('7 14 0r� /21? -C Phone:0-63) ?T 31 576€ <br /> City State,Zip 6:01,feta/®2 �'j,73-o 2- Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: <br /> Company Name: <br /> Signature: ...k.04 le# Date: 17 —q —Ali) 'l <br /> Address:�i23;'� 1-/ I-g- 6, 771 $ �t? - Phone:65273 5 I o 17 - <br /> City, State,Zip 1 m'*G d/ 9' F(-1 73/7 Fax: <br /> E-mail Address A b,c.K of ( 7227) Ace-, vi't <br /> DEQ License# CCB# <br /> G:\FORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />