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MARION COUNTY PUBLIC WORKS <br /> 4 BUILDING INSPECTION DIVISION <br /> l 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, 1 o c u \A O o\OPV�k. have authorized <br /> (Property Owner/Print Name) <br /> 161/41/10 .- Ni8,03CR, L R— 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 /> • <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 /> I`/UO Gv c f d iooc ( 4 ve , Iacuthoi, Ole 9735-0 <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description 1 Ij00 `�i\0Xtk_ , Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: Lair 1r ook.100ack <br /> Signature: "� Date: <br /> s- 22- 1 ' <br /> Address: %32_4{Vi • NDAGJL1&V� Phone: 503 <br /> City, State, Zip C y'tc ky(),\,k. 94'Z11 Fax: <br /> E-mail Address JAve,S le_ep 12S @ •Com <br /> AUTHORIZED REPRESENTATIVE:� / <br /> Printed Name: ,)4Vlgi VejtaQIxe _ <br /> Company Name: P"eC (S l0}/ C01/677r/'ad'b'i 23, CveA),(J6emit/co<'Ci! 2-L C— <br /> • <br /> Signatur;. "Ad / — Date: `(9- ' ( 9 <br /> Address: cl d5� �(V Phone: S-/ I _4 )/ " 2q 33 <br /> City, State, Zip 1Q. --SOY\. 0( q 7355- Fax: S/( 36 7' ice/-5YO <br /> E-mail Address pre_eAS-fertoraifr lG1 o'104 2615 <br /> DEQ License# • CCB# 9y9. 0-a p� <br /> GAFORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />