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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/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Anna A. King ,have authorized <br /> (Property Owner/Print Name) <br /> Tyler Gardner w/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 /> 115 maple St.Gates Oregon <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: <br /> Printed Nam : a A. <br /> Signature: <br /> Si Date: L <br /> g � �T <br /> Address: 12001 Chantal St.NE Phone: 11 1) Z2'(—?e 3 Q <br /> City, State,Zip Donald, OR 97020 Fax: <br /> E-mail Address G o 1tS \\S Vt u r l'Q C� rrxcl.1,( , C 6 Nti <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Tyler Gardner <br /> Company Name: Ken Tooze Excavation <br /> Signature: Date: 4/8/24 <br /> Address: 8624 Blackhawk Ct SE Phone:503-932-0484 <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 />