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19- X587- <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION E C p V E <br /> 5155 Silverton Rd NE P <br /> MAY 16 2019 <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MARION COUNTY <br /> http://www.co.marion.onus/PWBuildingInspection BUILDING INSPECTION <br /> NOTICE AUTHORIZING. REPRESENTATIVE <br /> I, Oct/415- <br /> tra7 ,have authorized <br /> (Property Owner/Print Name) <br /> MoLk rr to act as my agent in performing the <br /> Authori Representative/Print Name) <br /> p <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 /> s1.1s s frt.f-e 6 .sem S cp v 1 I Q'Q . 913 �- <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description SPelivii i2,4 /Ai skip 7 Soo)(R e 2—ant—Tax Lot#(s)( T2.14 e21C., 1 2-,3OO <br /> PROPERTY OWNER: / <br /> Printed Name: \ — ?CC Y <br /> Signature: <br /> / . <br /> Address: cILIs l- e S}-. S� Phone: t-1�-)1--(041—�°10 b <br /> City, State, Zip cC k.4M4 612 • TR Fax: <br /> E-mail Address ?pkAA,13 as h LB y p�,� • -O vw <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: t Ol,` r r <br /> Company Name: <br /> Signature: Date: C//1 `/4 <br /> Address: Phone. 3 ( 'I 490 3 <br /> City, State,Zip ,ccaeis.A1 D R T-3 1 Fax: <br /> _ E-mail Address r\kitAkk.e.r r @ G1 PflL, I •CO el"- <br /> DEQ <br /> ►^DEQ License# CCB # <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />