Laserfiche WebLink
May2519, 12:13a p.1 <br /> licti��, MARION COUNTY PUBLIC WORKS <br /> '�� n�'�"`��' BUILDING INSPECTION DIVISION <br /> . � �} 5155 Silverton Rd NE <br /> ` 4''''''''':'.° R017, ' Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http:/lwww.co.marioneor.us/PWIBuildingInspection <br /> 6 .NOTICE AUTHORIZING REPRESENTATIVE <br /> IA A_0, • /� 44— }(/J42" L-(- L.._._ have authorized . <br /> ,` Propertye , Owner I Print Name <br /> ) <br /> �,�r�v v. 6,4�,.,, to act as my agent in performing the <br /> (Authori ed 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 /> • <br /> PROPERTY IDENTIFICATION: <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description _Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> fi,4415, .PROPERTY OWNER: <br /> ,4/11` ....Li -. h....e: A Imo", A ' 1.6- i- <br /> Signature: A JIM WI <br /> Date: 20 i 1 <br /> • 4.ress: ✓/firb,.��i.,- _ •rte AMIFI ...• Phone:cO3•--7/9//—/.,e!‘, <br /> City,State,Zip' 0� — <br /> 3 0 -5 'Fax: ---- <br /> — <br /> ,E-mai <br /> l Address C��/Z 1 d ,' - CO`- - <br /> (gL.�yS FW9- -- CA,K,o! 1eAprY l- fC0� <br /> -AUTHORIZED REPRESENTATIVE: fifie-i- <br /> Printed Name: ___,A :-L.../Vi ` y`''am <br /> Company Name. 4t ,._!.--t___ • t_ <br /> ��r,„ <br /> Signature: / <br /> z Date: <br /> Phone: <br /> City,State,Zip c1 .74,2„,, (.2/43 - 0 72J Fax: <br /> E-mail Address "/ 1/ ' /.4.;,:-._ CO/-7 <br /> DEQ License# CCB# <br /> G:1FORMSISEPTICIS-67 AUTI-I TO APPLY.DOCX Rev 3/10,3/18 <br />