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MARION COUNTY PUBLIC WORKS
<br /> .00411 ,,,....,
<br /> BUILDING INSPECTION DIVISION
<br /> ---:-.. -...--------'7'''---_..--_.. _.,, •--N.---:........--.---..'"' -'t 5155 Silverthn Rd NE
<br /> m
<br /> MAR/ON CON
<br /> ''' 2
<br /> C,1E3fiVoi9EID
<br /> Salem OR 97305 ifI
<br /> (503)588-5147 Fax(503)588-7948 JAN 2
<br /> http:/Iwwcomarion.nr.us/PW/BuildingInspection i
<br /> BUIU
<br /> LDING INSpEcTr(oN
<br /> NOTICE AUTHORIZING REPRESENTATIVE
<br /> ie.-e__ et=c. /01.4,. / have authorized
<br /> ,
<br /> (Property Owner/Print Name)
<br /> • Z. (54,fie WA.,..., 4,.. .. tem.L:,...". a c, th act as my agent in petforming the
<br /> (Authorized Representative!Print Name)
<br /> activities necessary to obtain site evaluations,permits,and other Onsite wastewater treatmentprogram
<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 /> ,
<br /> .. (1/Z 6 LwAIZ,.40-) uulNy &-..,-• ,4 le eA c..)ke; crv, 77 31 7
<br /> Property Situs or Street.Address (-/
<br /> And described in the records of MARION County as:
<br /> Legal Description 0 7 1-.1-3 a A Tax Lot lks) 2 6 tr.)CI
<br /> • " •OPERTY OWNER:
<br /> Signature: /411"- • kt. cc.../0--1„J Date: ) 7
<br /> Address: i 3 (,ke,/toe k A a., u.JA/ 8 Phone: 7 7/ -A3 ?- c,3 6rai
<br /> City, State,Zip 5 A te,.....-- 0 P--e- er,,,.. 777/ 7 Fax
<br /> E-mailAddress te_e_.. dy,e r i e tortfrg 0 Reg a..,.=.8. ottd
<br /> AUTHORIZED REPRESENTATIVE:
<br /> Printed Name: Z. .....s.4.44e •114,4,,4r... Yerc.L.L•64-a%c..-%
<br /> Company Name: M.: kce 14 4 ...,, er
<br /> Signature: ___.161 € Date: 1- 7- f '7
<br /> Ackires : 3.2 /se e f5 - - led Phone: 5 cv- </14,- Z-1.7/
<br /> City, State,Zip4,,,,,,„ c g .50 7 3ç 5- Fax: 5q(- a 5-4? - efyci I
<br /> E-mail Address I 5 e„ii e ("Z c,c fc•4-ac,_tok 0 s,e +-s., .c. ...--1
<br /> DEQ License# 1•7 /a a • CCB# a-L1 /3.c.,
<br /> GAFORMS\SEPTIC\S-07 Auth to Applyloc
<br /> MCS-07 key 03/10
<br /> SEPTIC 4.
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