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MARION COUNTY PUBLIC WORKS <br /> AI ,,' BUILDING INSPECTION DIVISION <br /> NM <br /> �u: <br /> �� ti. 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 /> r: <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, Irene van Loon ,have authorized <br /> (Property Owner/Print Name) <br /> Logan Benjamin,Groundbreaking 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 /> -43+21 Jefferson Hwy 99E SE, Jefferson, OR 97352 <br /> I VA 1 Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description 093W260000600 Tax Lot#(s)536516 <br /> PROPERTY OWNER: <br /> Printed Name: Kryn & Irene van Loon <br /> Signature: Atilt, Van, :C am, Date: 08/02/2024 <br /> Address: 13121 Jefferson Hwy 99E SE Phone:541-974-4699 <br /> City,State,Zip Jefferson, OR 97352 Fax:n/a <br /> E-mail Address krynirene@hotmail.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Logan Benjamin <br /> Company Name: Groundbreaking Excavation LLC <br /> Signature: !.__� Date: <br /> Address: PO Bo 6 0 Phone:503-884-6296 <br /> City,State,Zip Lyons Fax:n/a <br /> E-mail Address groundbreakingexc@gmail.com <br /> DEQ License# 39191 CCB# 219731 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />