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,,,' <br /> .��I ,,��� ... MARION COUNTY PUBLIC WORKS <br /> �'''IlrBUILDING INSPECTION DIVISION <br /> ��il�v 5155 Silverton Rd NE (I <br /> ism- Salem OR 97305 0) EC E 11 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/Buildinglnspection LI 11 jAN 25 2019 <br /> MAFiION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, V t\- V' -71-- 5Uel-tc-Frac. 4uott_ov.. kly ,have authorized <br /> (PropertyO r/P ' t N. lie) <br /> AY dihe Ma ei 7O r ,AwAs It 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: rr ,' <br /> -S L BGZS. / S t. N . f fa Yee/ *12 l jG,S';'1 .a S/'7° <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description j(A-s t l P61.5 ).-e Tax Lot#(s) 2- <br /> PROPERTY OWNER: • <br /> Printed Name:Cl/,PsKa--"►o W alcakt <br /> Signature: ( Date: l 21z 8 l I F <br /> Address: PO 7( 5607 j19Eq.7L Di/Phone: 57)2 - '/- i y(0 <br /> City, State, Zip Fax: �I - S12 S-- 06 0/ <br /> E-mail Address W 01 a,,,-,a.iinova v Ic-ci, f .4 e Ci mai t. cowl_ <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: h d' Ma Ka v.ei1 <br /> Company Name CNl.p,r S (IC <br /> r / _/ I <br /> Signature: 0 Date: —2 <br /> Address: :• %07 Phone: So�SV/c/) <br /> City, State, Zip czbate17 sYFax: 5 v3'S M'O(0D1 <br /> E-mail Address ev(,r yi-6-0 c p0 1.-,e6(444;(:rco <br /> DEQ License# 7 CCB # 1x20 2 q <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />