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214-o-o 3(t,lq Pe-Air <br /> \,%, MARION COUNTY PUBLICWORICS <br /> • .11111111 4144.. <br /> .111/c BUILDING INSPECTION DIVISION <br /> -"*"-ms`'''' -•- •":""---.. -.z.":40"i't 5155 Silverton Rd NE <br /> _______ <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, 5 6stfiN. V.:04VA\ have authorized <br /> Mi (Property <br /> Owner/Print Name) . . <br /> , : ah Hozen - reation Contracting 1 <br /> (Authorized Representative/:.pt Name) to act as my agent in performing the <br /> activit es necessary to obtain site evaluations, permits, and other onsite wastewater treatment program <br /> servic s provided by the Department of Environmental Quality or County Agent on the property <br /> descried below in aCcordance with OAR chapter 340, division 071. <br /> PROIIERTY IDENTIFICATION: <br /> 3‘*""1 1\-Nto.cX eltA3S 1—VN, -5t)carSefri 0 C- <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdiviion,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: *3 ess‘Ap\r,‘ i•AAJA.L\ \ <br /> Signatore: Date 'Lk/IC igA <br /> i I <br /> Address: INX71 ‘...k.toAce thIc 1-,Y‘4 Phone: Cc11-a‘e,- <br /> ! <br /> City, State, Zip Fax: <br /> „ <br /> E-maii Address : \ t) ' <br /> AUTHORIZED REPRESENTATIVE! <br /> Printed Name: Micah Hozen, <br /> Company Name:, New Creation Contracting <br /> Signature:_.-, Date: 2/7/2024 <br /> Address: 31366 Oak Plain Dr. Phone: 503-710-2565 <br /> City; State,Zip. Halsey, Oregon, 97348 Fax: <br /> E-mail Address micah@newcreationco.net <br /> DEQ License it 38988 CCB# 201065 <br /> • <br /> 0:NVORNI/l 'ErTICS-07 Atm tTo Al'i'LY.DOCX lisxt3/10,3/1B <br /> 1 <br /> • - <br />