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e5aLes22,) <br /> a . <br /> • ."itz- MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, David Holloway have authorized <br /> (Property Owner/Print Name) <br /> Speedy Septic _ to act as my agent in performing <br /> the (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 /> IDEWIFICATION: - <br /> -30415 - fitotaAtek me! <br /> Property Situs Pr Street Address- <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) oSi tA) v*. crl S cc.' <br /> Subdivision, Lot-and Block <br /> PROPERTY OWNER:. <br /> Printed Name:. DaVid Holloway <br /> Signature: ; Date 4-1-24 <br /> Ird.47f <br /> Address: 3095 Molalla Rd Phone: 808-212-8967 <br /> City, State, Zip 3095 Molalla Rd, Woodbuni, OR .97071 <br /> Fax: <br /> E-mail Address _ Davidrholloway860gmaiteom _ <br /> AUTHO ° 4 .:'REPRESENTATIVE: <br /> Printed Name 6tô610Vv)Cit, <br /> Company Name:_ <br /> Signature: ' <br /> Address: Y. 0, r-SCAL, q 1 , _ • Phone <br /> City, State, ,t(r)g, Fax <br /> -E-mail Address 6-70 4 Corrt 3S-1 u_o <br /> GAFORMS‘SEPTICAS-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />