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1 <br /> DocuSign Envelope ID:B75A87E6-632E-1A5E-919F-C3527350EE04 6 6 G 6-51- ' 110'1 <br /> I <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> -����i_ = 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.onus/PWBuildinglnspection <br /> s. <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Steve Broady <br /> I, have authorized <br /> (Property Owner/Print Name) <br /> Thomas Holland/J.A. Holland construction 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 /> 17085 wall Ln SE Jefferson OR 97352 <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) R37322 <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Steve Broady <br /> Printed , 1/21/2022 3:12:23 PM PST <br /> Signatu :c t ut, f r'ea� Date: <br /> �'523j�har Dr. 503-977-9761 <br /> Address: Phone: <br /> City, State,Zip Portland, OR 97223 Fax: <br /> E-mail Address badferret420@gmail.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Thomas Holland <br /> J.I. Holland construction <br /> Company Name: _ <br /> Signature: tsysrf' Date: /" 2/'" 2O 2 2- <br /> Address: 4143 way an ,r CI. 507 Phone: 541'379 $/( <br /> City, State,Zip 54/PN// , O/`� q 7 7/ 7 Fax: <br /> E-mail Address J.4. j!'4/�an ci (OAS i4"o hay <br /> DEQ License# 3143-1 CCB# 2341(r <br /> G:IFORMS\SEPTICIS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />