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MARION COUNTY PUBLIC WORKS <br /> 4 BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> �• - ' Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://.www.co.marion.or.us/PWBuildingInspection <br /> i <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, DtaisA A c er: Frasier_ have authorized <br /> -� (Property Owner/Print Name) <br /> g X 0 EA i?) 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 /> tv 1 3 B 1,!tr xn©b Aic 97315 <br /> Property Situs or Street Address . <br /> P <br /> Described in the records of MARION County as: 0714616Legal Description Tax Lot#(s) / <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name �r'j Cl O ke-5 <br /> Signature: �.%r ��� Date: <br /> Address: P() Sc7C c(03 Phone: cej2 i972 <br /> City, State, Zip3ilu-6/-4-01'J (3✓Z / 7 Fax: <br /> E-mail Address da foth - , c -Mc& 4 QoN^ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Zi( -goiffzi <br /> Company Name: !J <br /> Signature: �� � Date: 7 43 <br /> Address: - y _ „' d I Phone: 5 o 3 .- S 7 i . G 7 7 f <br /> City, State,Zip 3eik ( / Q(Z . et 700F Fax: <br /> E-mail Address a r(-Sryvng.r-e A 3m.rJ Cz;►-� <br /> DEQ License# c� CCB# <br /> • <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />