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Innovative Environmental Services <br />1 <br />PO Box 56 <br />Toms Brook Va 22660 <br />Phone: 703-856-6273 <br />InnovativeEnv@outlook.com <br />Signature Affidavit for Loudoun County Environmental Health Submissions <br />Property Address: ____________________________________________________ <br />Pin #: ___________________ <br />Subdivision: _________________________ Lot #: _______ <br />I authorize Innovative Environmental Services to sign as my agent any applications <br />pertaining to Well and Septic Systems on the properties that we are currently working <br />on. <br />I also give permission to the Virginia Department of Health and Innovative <br />Environmental Services to enter on to the property described during normal business <br />hours for the purpose of processing the application and to perform quality assurance <br />checks of evaluations and designs certified by a private sector Onsite Soil Evaluator or <br />Professional Engineer as necessary until the sewage disposal system and/or private <br />water supply has been constructed and approved. <br />Legal Owner ______________________________ <br />(Print Name, Required Current Legal Owner) <br />Signature _________________________________ Date _____________ <br />Quarter Branch Road <br />294-25-5718 <br />Quarter Branch 1,3,5,6,8,9,10,11,12,14,16,17,18,19 <br />Jonathan Kennedy on behalf of Quarter Branch LLC <br />DocuSign Envelope ID: F25FF1B0-75EC-4D2E-8448-D1F7AD11EE66 <br />9/21/2023