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,,ii MARION COUNTY PUBLIC WORKS I <br /> "''' • <br /> BUILDING INSPECTION DIVISION D IECIEENI <br /> %���-tto 5155 Silverton Rd NE_= Salem OR 97305 MAY 0 4 2022 <br /> (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, DONNA PETERS ,have authorized <br /> (Property Owner/Print Name) <br /> Ken Tooze Excavation 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 /> 992 IVA LANE NE SALEM, OR 97317 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s)072W20D001300 <br /> PROPERTY OWNER: <br /> Printed Name: DONNA PETERS <br /> Signature: 0 onin a 6 t Date: 1/- -Z(.-.7 <br /> Address: 992 IVA LANE NE Phone: 50 S c /- /G'J9ce <br /> City, State,Zip SALEM, OR 97317 Fax: <br /> E-mail Address dip c-4oa1der )v inat/, NW)?? <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: KEN TOOZE <br /> Company Name: KEN TODZE EXCAVATION <br /> Signature: Ji '�% �� Date: 4-22-22 <br /> Address: 86 4 BLACKHAWK CT SE Phone:503-932-4175 <br /> City, State,Zip SALEM, OR 97317 Fax: <br /> E-mail Address kwtexcavation@aol.com <br /> DEQ License# 39231 CCB # 165848 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />