Laserfiche WebLink
11•x, MARION COUNTY PUBLIC WORKS • <br /> •°� �"�'"0j" BUILDING INSPECTION DIVISION <br /> j�`� � 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Far(503) 588-7948 <br /> http://www.co.marion.onus/PW/Buildinghtpection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, . _s t- _. 111) ‘• • _ , • A M- d . ..i ve authorized <br /> (Pr.i.erty Owner-/-Print-Name) <br /> 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 /> 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 /> &5/✓ /doh s Cci SU %ur--,e i OE 97,393 , <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 /> • Printed Name: i..t. , L, .dr a _. _ s ■! r , _ _ _ •.-... f <br /> Signature: ie,_A 4 . , _. _ Date: /_ ____ cDa <br /> ddress: S . jam . - Phone: 50 569 .3S63' <br /> City, State, Lip -7-4-4-J.--x4j 02 67)39...a_ Fax: <br /> E-mail Address kottLci( ynxe bri A q e t na , Gtl�-td. ( n--. <br /> AUTHORIZED REPRESENTATIVE: <br /> I �1 <br /> Printed Name: y nv tt, 1- ILS-TALL . <br /> Company I( : '�I�- f- c • <br /> Signature: j/ v it <br /> Z)L Date: 7C t� -23 (4) <br /> Address: J r Q 36 1' 41 ci Phone: 7 U - G3 S <br /> City, State, Zip 'rOr/VLL. OY . C-rr 3 4 R Fax: <br /> E-mail Address <br /> DEQ License# 361 qfP, CCB # UctSS <br /> G:IFORMS1SEPTIOS-07 Audi to Apply.doe <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />