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t..,, MARION COUNTY PUBLIC WORKS 1 E <br /> - _��1'= ` BUILDING INSPECTION DIVISION V <br /> :',... ..44..... ..." 5155 Silverton Rd NE _ <br /> - � - Salem OR 97305 MAY 14 2019 �� <br /> - _: - •" _ (503) 588-5147 Fax(503) 588-7948 MARION COUNTY . <br /> -12,i:2-.-,-_---,..,_-....:,-,-_-_-_--z-,-., http://wvvw.co.mariomor.us/PWBuildingTnspection BUILDING INSPECTION <br /> - • • NOTICE AUTHORIZING. RERRESENTATWE <br /> I, • h?riIn A t°,S covii\5- ,have authorized •. <br /> Property Owner/Print Name) • • <br /> hie(l m- "G-se,_t. i ez- to act as my agent in performing the <br /> (Authorized Representative/Print Name) - . <br /> activities necessary to obtain site evatnafions,permits, and other onsite wastewater treatment program <br /> services provided by the Department of Environmental Qnality or County Agent on the property <br /> • described below in accordance with OAR chapter 340, division 071. <br /> • <br /> PROPERTY IDENTIFICATION: • <br /> 1 °I S? TtpeSoks Lv. S S:Iv-e(= 'ti i9;12-,_.c)7381 <br /> Property Sitar or Street Address <br /> • <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) _ (.0 O 0 - • - - <br /> PROPL<'RTY OWNER: <br /> • <br /> Printed Name: r - 4 . . <br /> Signature: „k,j14. �.,.-- Date: '- l 3 -1 Q <br /> Address: i 0)5 c)O Set-.4-i c Lr . S� . . Phone: -03- 7 3.-3L0-7 - <br /> City, State, ZP S 1 k`ev 4-ar\ ) r-. 1 Fax: ' -c •� <br /> E-mail Address t4 • .; t iv.. ` L <br /> a t,,.e. r y-L-1 Lip a O(.cc) <br /> AUTHORIZED REPRESENTATIVE: - <br /> Printed Name: .-3:::)ar\-k0IIe I'•VI . aohAv-eZ - <br /> Company Name: // - <br /> .. • Signature: ( c.0,,,,, - l A Date: 5----1 3 --19 <br /> Address: 'I:a►5( tse ck r\ i S L . C g” Phone: '5(..)• , (-)01Colo L f <br /> City, State,-Zip Si`v-e-4. ` . -Ci-? Fax: . . <br /> E-mail Address DI ca rn ic-I l en v e•z Co O 04-j cao k..c o o-, • • <br /> DEQ License#. ' CCB# <br /> . G:\FORMS\SEPTIC S-07 Ash to Apply.doc • <br /> - - <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />