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DocuSign Envelope ID:68E3353E-0D54-4408-BF25-5F706B091DD5 <br /> 8 �Q <br /> MARION COUNTY PUBLIC WORKS �� I "� � <br /> BUILDING INSPECTION DIVISION <br /> un: RECEOVIED% 5155 Silverton Rd NE Salem OR 97305 <br /> (503)588-5147 Fax(503) 588-7948 AUG 2 2023 <br /> http://www.co.marion.or.us/PWBuildingInspection <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Joelle Camillo Executor of the Estate of Thomas M Hosford have authorized <br /> (Property Owner/Print Name) <br /> Micah Hozen - New Creation Contracting _ 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 /> 13453 Marlatt Rd, Jefferson, OR <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: Tax ID 536581 <br /> Legal Description _ Tax Lot#(s) 093W30A002700 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Joelle Camillo Executor of the Estate of Thomas M Hosford <br /> Printed Name: <br /> DocuSigned by: <br /> Signature: C� Ga,,,�(� Date: 8/22/2023 <br /> Address: 'IA90C805911E4c7...2150 Bunker Ridge Rd S Phone: 503-798-1559 <br /> City, State, Zip Salem, OR 97306 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Micah Hozen <br /> Company Name: New Creation Contracting <br /> Signature: _ Date: 7/6/2023 <br /> Address: 343 Kirk Ave Phone: 503-710-2565 <br /> City, State,Zip Brownsville, Oregon 97327 Fax: <br /> E-mail Address micah@newcreationco.net <br /> DEQ License# 38988 CCB# 201065 <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />