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Fe <br /> Apr 0416 02'.34p p.1 <br /> a <br /> , (2b <br /> t •, MARION G HISRE PUBLIC WORKS :�j—�EC <br /> E V E 0 <br /> ' � BVII.DAVGINSPECTIONDIVISION I v <br /> 5155 Silverton Rd ,r- <br /> Sal _o� v(5O ' I. _��.PR O4 2015— <br /> `1.1111 <br /> ; (503)588-51.7 as 503)588-794: • <br /> J b.ttn:I/www.ca.mario, I...aa/PWB•. din• yw- toe NIARION COUNTY <br /> ��w�e BUILDING INSPECTION <br /> • <br /> NOTICE AUTHORIZING REPRESENTA 'NE <br /> --rr ,have autharized <br /> 'I,r. ' ifHan 4✓`P Fa✓nS .FM1G. <br /> (Property Owner/Print Name) <br /> T-• 2-;9 4;,' to act as nl rgeat m perfuming the <br /> (Authorized Representative/Priut Name) - <br /> activities necessary to obtain site evaluations,permits,and other ons:'te was water treatment program <br /> • <br /> services provided by the Department of Environmental Quality Cr County F put on the property <br /> described below in accordance with OAR chapter 340,division 071. <br /> PROPERTY IDENTIFICATION: <br /> .. <br /> -370/ /H' 4:(• St, 4.I, OA 41747 . . <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s' • . <br /> PROPERTY OWNER: <br /> ' PrintedName:to /x 22:11-4.1.---;----'-------- <br /> Signahae: Ce5/1 ..nom '�"" '--- Date:- Y- r!- '4 . <br /> -e) <br /> f Address: 3801 Alla:04., seat F . . ?hone: cP3 633-2-5/Z <br /> City: Stere,Zap ft. 444 OA 47/37 Fair: 573 633 - 2-373 <br /> • <br /> Ei-mailgnanae:dresAds <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: . 77, 2.'Pb;fk• <br /> Company Name: . <br /> S ^ . <br /> Address: 170/ Mir$:0,1 - 4 N6 <br /> Phone: cos pill-7.a 3d - - <br /> ity,State,Zip Si. A.; Obi 57/3 7 <br /> Dau: 4-4-4Fax'_ • <br /> E-mail Address • <br /> • DEQ License# - ' CO# <br /> Oteoaas'Eerrct%a;Aut Appq.aec <br /> MCS-07 Rev ay10 4 " <br /> SEPTIC <br />