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^v, MARION COUNTY PUBLIC WORKS D E C 10 V BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE MAR 23 2022 <br /> '' Salem OR 97305 <br /> (503) 588-5147 Fax(503) 588-7948 MARIONCOUNTY <br /> http://www.co.marion.or.us/PW/BuildingInspection BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, fit/ ,have authorized <br /> (Property Owner/Print Name) <br /> Katie,Dennis and Lee 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 /> t..o11Lk ( eve. ' So, . QQ °c t - <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 Name: c.✓c tc/ � G�CiLi <br /> Signature: • Date: <br /> Address: 6 2.7 4 r v e tri Phone: 52)3-, 1-a(a-7 <br /> City, State,Zip -S;je� '7'-7.3 ( 7 Fax: <br /> E-mail Address <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Katie Ryan <br /> Company Na e: Bethel Excavating <br /> Signature: Date: 3),a t PO Box 504 Phone:503743-) o- <br /> Address: 343 <br /> City, State,Zip Turner, OR 97392 Fax:N/A <br /> E-mail Addressoffice@bethelexc.com <br /> DEQ License# 36198 CCB# 44551 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />