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• <br /> 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/PWBuildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> i <br /> I, ��i eY &5h1L ,have authorized <br /> (Property Owner/Print Name) <br /> Katie Ryan 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 /> -z_q_79Alatetau. (roilAD <br /> Property Situs or Street Address lift V , OC. <br /> And described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> PROPERTY OWNER: xn <br /> Printed Name: . 1 la In. tr1:13A-0 <br /> Signature: f ,/-�� Date: L T 161.23 p -7 <br /> Address: [') �g� i/ (Phone: Cn.' ' (,l7 / y <br /> City,State,Zip / g73/7 Fax: /60s <br /> E-mail Address 27 I or /?-e 6_)� <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Katie Ryan <br /> • Company Name: Bethel Excavating <br /> Signature: Date: <br /> Address: PO Box 504 Phone: 503-743-2343 <br /> City, State,Zip Turner, OR 97392 Fax: 503-743-3638 <br /> E-mail Address officeabethelexc.corn <br /> DEQ License# 36198 CCB # 44551 <br /> G:1FOR1v1SlSEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />