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MARION COUNTY PUBLIC WORKS (�/ of <br /> "� BUILDING INSPECTION DIVISION /(, .0 06,5 <br /> ��i`�:�`w 5155 Silverton Rd NE d <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.Co.martin.or.us/PW/Buildinginspection <br /> • <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, 4/Wi ✓1t t h. }W (,Ua j(t (IldatiA[iy , have authorized <br /> L <br /> (Property er/Print Name) / <br /> 011-51"b Stioki. ¢ E to act as my agent in performing the <br /> (Authori2ed 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 /> PROPERTY IDENTIFICATION: <br /> 2i€65S L:-41a. M.-C& PSL itaata OR etfRA <br /> Property Situs or Street Address <br /> And described in the recordsofMARION County as: L ,� <br /> Legal Description 442 t Tax Lot#(s)14etbk g 1{(3er7 <br /> PROPERTY OWNER: ' p0 <br /> Printed Name: 00;16)10144.0-per- <br /> t 6' .41. L51 <br /> Signature: ,^l ••,'- r pe toil t m Date: ?.(27(1$1 <br /> Address: CY ` /� � Phone:6b$ V70^Cn005 <br /> City, State,Zip as Lew- CR 003v I Fax: 9b3 31.6-534./, <br /> E-mail Address trtn+w Cu);`ICAr.a_- - .tt((.. <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: fTOUCe a krill fez-- <br /> Company Name: fln-Sl�t' Sep{-i c ; 5Cc u,a. hrr%, <br /> Signature: at,- t•r ,c 0.7 Date: OZ127/2018 <br /> Address: c`iCI).(1, .. g 4 ( Phone: 503 3(.2- 7006 <br /> City, State,Zip 3ctl n-, lf1 Q7304 Fax: <br /> E-mail Address 01/15 zt'80r1[roil i 0- Cdwt <br /> DEQ License# 3/078 E, CCB# 1661134 <br /> G:IFORMSISEP IC\S-07 Aut to Apply doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />