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Zc '111/42-e <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> „FF.: <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.orms/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, , a./IA-,t,5 tAj 00'`) S ,have authorized <br /> (P operty Owner/Print Name) <br /> al - / e. C. , - - -. d o act as my agent in performing the <br /> (Authorized Representative/Print 'ame) <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 /> 3° 0 ';(S>( S'( Stia tis /11115 Orr. 973 -75 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 04 //g/.S , ) G 0 O Tax Lot#(s) 20 0 <br /> PROPERTY OWNER: <br /> Printed Name: 1%.4. 'w -5 1- S <br /> Signature: If (A) Date: Z? d <br /> Address: 91- ( )Ak Phone: 5-O 3 -5 9 <br /> City, State, Zip , c e'tbT t .14( rt. 0113.7 C Fax: <br /> E-mail Address J i M w N,i4 y $ ed G� o a,C o iv\, <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: / e r d e r f C. i2i Iso Kof rr. <br /> Company Name: 10e fru eor iter Sep%G6 1 w& <br /> Date: ,:- 5 -- / 9 <br /> Address: 87 7 Z. C A 5 C 4 cie /1 uyv `1! Phone: 6�(, 3-F73- 71J7 <br /> City, State, Zip 5, ) ✓e d /e k cifkv, Q 7381 Fax:,KOC- f'73 J 5 4 - <br /> E-mail Address I o Il a?IN L 6e/ t le 5 8 77 2 ( lLa i l . L ) HA.. <br /> DEQ License# 3760 3 CCB# / 7 7 0 / 3 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />