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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE EC <br /> E1 OR 97305 `J `- <br /> ..t <br /> (503) 588-5147 Fax (503) 588-7948 j <br /> AUG 1 ® 2018 <br /> www.co.marion.or.us/PW/BuildingInstsection <br /> iANION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> O\n.b.\ \ \ S ,have authorized <br /> Property Owner/Print Name) <br /> r.d ` tp\ to act as my agent in performing the <br /> ( thorized presentative/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 /> se \ Lk � a�� a s� sem\@N kV; \.-1 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description TAS•D 2\1 Tax Lot#(s) \% a 0 <br /> PROPERTY OWNER: <br /> Printed Name: o�— 'N�'� s <br /> Signature: � ,� Date: C - V- \b <br /> Address: S'1 SS Phone: S o -3 1/4-k-1 Li <br /> City, State,Zip S o,\ 0.'13\'Z Fax: <br /> E-mail Address Y *NA-c'\S ® v\ac Q,1Y%t\Ov.c':1ti Cs-5. C o\n_. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: r ear - _.. ; 1 \ la <br /> Company Name: 44' / /LT'4 it \$\ _i i i .i, <br /> Signature: :ter i "A#1). ,r4,1, Dat• cis -�; T <br /> Address `�d'`r_ 91/'_J �.� c„0, R Phone: .3-660- i q23 <br /> City, State,Zip \-‘0 Anqr‘. ®' q1 Fax: 41/ <br /> E-mail Address c\ctO `c\k�sR. <br /> i e_ �' c��C ca (/c Or\ \ no.). x'11 <br /> no.).cr \ <br /> �"r <br /> DEQ License# '3 '( q,c, C U J# <br /> G:\FORMS\SEPTIC\Application Packets\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />