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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION �a^ DES <br /> ,� 5155 Silverton Rd NE [o E ii V[ <br /> Salem OR 97305 <br /> (503) 588-5147 Fax (503) 588-7948 �' <br /> http://www.co.marion.or.us/PW/BuildingInspection NOV 1 2022 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Dale Smith , have authorized <br /> (Property Owner/Print Name) <br /> Jesus Andrade/3-A Construction, LLC. 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 Depaitiiient of Environmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> 8028 Jorgensen Ln SE, Salem, OR 97317 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 082W11 D Tax Lot#(s)03000 <br /> PROPERTY OWNER: <br /> Printed Name: Dale Smith <br /> • <br /> Signature: Dale Sm B 10,202216:42 PDT) Date: Aug 10, 2022 <br /> Address: 8028 Jorgensen Ln SE Phone: 503-576-0206 <br /> City, State, Zip Salem, OR 97317 Fax: <br /> E-mail Address djsmith9652gmail.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Jesus Andrade <br /> Company Name: 3-A Construction, LLC. <br /> Signature: 2S4fJ/- , Date: Aug 10, 2022 <br /> Address: 1690 Harvey St SE Phone:971-218-3568 <br /> City, State, Zip Jefferson, OR 97352 Fax: <br /> E-mail Address info@3aoregon.com <br /> DEQ License# 39002 CCB # 167959 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />