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21'Y-003 z% gr'U T1 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 Fax(503)588-7948 <br /> http://www.co.marion.or.us/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Thomas R and Roxielliga L Burns have authorized <br /> (Property Owner/Print Name) <br /> Kiel W. Brown of On-Site Septic and 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 /> 2611 Jory Hill Rd S, Salem, OR 97306 <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description 083W2OB Tax Lot#(s)001400 <br /> Subdivision, Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: Thomas <br /> and Roxiellia Burns <br /> Signature: ar '1L V(A/C/L6l "� �;6 Date: `J 2 L/1-25/1 <br /> Address:2611 Jory Hill Rd S Phone:503 949 2798 <br /> City, State,Zip Salem, OR 97306 Fax: <br /> E-mail Address roxburns333@gmail.corn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Kiel W. Brown <br /> Company Name: On-Site Septic and Excavation <br /> Signature: ��� _ Date: 3/28/2024 <br /> Address: 40110 Providence Dr Phone:503-362-7000 <br /> City, State, Zip Scio, OR 97374 Fax: <br /> E-mail Address OnsiteEx541@gmail.com <br /> DEQ License# 39705 CCB # 250476 <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />