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MARION COUNTY PUBLIC WORKS JUN 30 2023 i <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE MARION CuUN iY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.marion.onus/PW/Buildinginspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> 1, 7a re FroS I- I Gx.S e,C ,have authorized <br /> (Property Owner/Print Name) <br /> lien I ooze excavation Inc. 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 /> 5575 Fruitland RD NE <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s)072W21 CC03300 <br /> PROPERTY OWNER: 1 I <br /> Printed Name: --ea * sleet Sa el,1.11 I/�(t ��k��YT")�� pi <br /> Signature: _ Date: 6/ 15/2 3 <br /> Address: G S-15. ,ru I I Ur `k d 1 Phone: 503-5 <br /> City,State,Zip SCI61 0 f Fax: <br /> E-mail Address JaS,ni.S C LIIIapYS!C, , COkVt <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Tyler Gardner <br /> Company Name: Ken Tooze Excavation Inc. <br /> Signature: `�► 2. 64 v.8.1 c Date: 6-14-23 <br /> Address: 8624 Blackhawk CT NE PhO1C:503-932-0484 <br /> City,state,zip Salem OR 97317 Fax:503-391-0530 <br /> E-mail Address kwtexcavation@aol.com <br /> aol.com <br /> DEQ License# 39231 CCB# 165848 <br /> G:\FORNIS1SEPTICkS-07 Auth to Apply.duc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />