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•,, MARION COUNTY PUBLIC'WORKS L n 5 <br /> BUILDING INSPECTION DIVISION �I <br /> — �,�•� 5155 Silvcrton.Rd NE <br /> Salem>OR 97305 <br /> (503)588-5147 Fax(503)588.7948. AUG 0 202�4 <br /> http:flwww cu:marion.or us1PWiBaild ngInspe�etlon <br /> NOTICE,AU TRORIZING REPRESENTATIVE <br /> I, 41An syn /tv1 have authorized <br /> ( perty Owner/Print Name) . <br /> Micah Hozen - Pro <br /> Creation"Contracting 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 /> 4iS50 NtLrt 4nibA,yi A c' 47350 <br /> Property Sius or Street Address <br /> Described in the records of lvIARION County <br /> Legal Description 7 1 6�.:-Z tD 4 i 300 . Tax Lot"#(s) <br /> Subdivision,Lot and Block rtj 6-5(0-ili <br /> PROPERTY OWNER: <br /> Printed NameIL kl.Sa 1 4c„v1 <br /> ��-� a _ <br /> J <br /> Signature: / � . <br /> `�`f tC„f f .1---'Hate:. ` to ;C; . <br /> Address: � <br /> ea GC ." Phone: --9I47`-e6'?7 <br /> City,State,Zip, -- i .Std Q.f° Fax: <br /> Email Address ,d6e. - <br /> 61ru.'e-km a v,stc.ft a o t, c...c <br /> AUTHORIZED REPRESENTATIVE:. <br /> printed Name: Micah Hozen <br /> CompanyNe: New Creation Contracting <br /> Signature:,, Date: 2/7/2024 <br /> Address: 31366 Oak Plaint Dr. Phone:503-710-25.65 <br /> City,state Zip Halsey. Oregon, 97348 Fax <br /> E-mail Address rnicah @newcre:ationCo.itet <br /> DEQ License# 38988 CCB# 201065 <br /> GAFCtR.' TSEP7RC''&07 AIM TO-APPLY.DOcX Rev 3V10,3i18 <br />