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MARION COUNTY PUBLIC WORKS <br /> • <br /> WILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE ICEnrE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection U MAY 22 2019 <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Kevin Crosby ,have authorized <br /> (Property Owner Print Name) <br /> Brandon Hicks 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 /> 8648 Crosby RD NE, Woodburn, OR 97071 <br /> Property:Situs or Street Address <br /> And described in the records of MARION County as: <br /> Acres 41.24,19-20:Deferred Additional Tax Liability SB125.18$2110 052W01.01200 <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Name: K yirICr by <br /> Signature- Date: 3 - ? <br /> Address: 86 8 Crosby Rcc-1--/E Phone:503-982-5166 <br /> City, State,Zip Woodburn, OR 97071 Fax:503-981-2141 <br /> E-mail Address hops@crosbyhops.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Brandon Printed Name: Hicks <br /> Company Name: Jim Hicks Excavating <br /> Signature:. Date: 17- /1 <br /> Address: ? o b 6, 9 / Phone: 9// -J-70- 17W <br /> City, State,Zip Ca xi t$N7 ore.- €V713) 3 Fax: <br /> E-mail Address /8 I o 14 Jom (411,1c./ '4 L1c4 e 4; • t. 0 A. <br /> DEQ License# 2 co "7 Y 8 CCB# 9 crbq 3 <br /> GAFORMSISEPTICAApplication Packets1S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 .0 j- I5- <br /> SEPTIC 4 <br /> 5,(V) <br />