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MARION COUNTY PUBLIC WORKS <br /> Jur BUILDING R EC <br /> 1 1 EGVE <br /> NGNSPECTION DIVISION <br /> „........ ......_..„ <br /> 5155 Silverton Rd NE MAY 17 2023 <br /> Salem OR 97305 <br /> MARI°N COU <br /> (503)588-5147 Fax(503)588-7948 I:UILDING NTY <br /> http://www.co.marion-or.us/PW/BuildingInspection INSPECTION <br /> i <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Hwy 99 LLC _ ,, have authorized , <br /> (Property Owner/Print Name) <br /> A-Affordable Septic Service 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 /> 12120 Ingalls Ln Woodburn,OR 97071 <br /> Property Situs or Street Address <br /> Described in the.records of MARION Comity as:. <br /> Legal Description Tax Lot#(s) <br /> Stibdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name; Hwy 99 LLC <br /> Signature: 1.kt,-. te &V__ k?y....(5; <br /> ill Date: c1 kit 7,2, <br /> .... <br /> Address: PO Box 1: 0 Phone: <br /> City,State,Zip Wilsonville,OR 97070 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> printed Naj3::Le: Rick Jonas <br /> —Company N <br /> Signatre /77, <br /> 5f-o <br /> Date 5-n -QS <br /> Address: PO Box 81a Phone: 503-682-1929 <br /> City,.State,Zip Canby,OR 97013 ., Fax: <br /> E-mail.Address dessa@ionasconvv.corn <br /> DEQ License# 37918 CCB# 158246 <br /> GAFORIviSLSEFIIOS-07 ADM TO AFPLY_DOCC Rev.3/10,3/18 <br />