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MARION COUNTY PUBLIC WORKS <br /> ,ii 11 "7" BUILDING INSPECTION DIVISION <br /> 1����. 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> MI <br /> (503)588-5147 Fax(503) 588-7948 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, DAB t.6 i .. PArrig450Q have authorized <br /> (Property Owner/Print Name) <br /> Lee Bethel-Bethel Excavating 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 /> 4 ,."o i.,e r , Lv 36 No k ile 5 `It:pc)✓ <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: 090210 67 d L CO I $cC <br /> Legal Description,503 .0 ( 'S 201(,J VI,K Tax Lot#(s) I Jo O <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: i5 ratSoNI fTE'LSC J P*A (X fb2 L..L.0 <br /> Signature: () - M evki3Gt. Date: 7/25 /20 23 <br /> Address: fO"Bo's 1 ,2.?i Phone: '111(--94 _t-F34-q <br /> City, State,Zip B0, , 0R , .1 770 7 Fax: <br /> E-mail Address DL.._PCO ,S/O.-AoL, c ' <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee Bethel <br /> Company Name: Bethel Excavating <br /> Signature: Date: <br /> Address: PO Box 504-6976 Little Rd SE Phone: 503-743-2343 <br /> City, State,Zip Turner, OR 97392 Fax: NA <br /> E-mail Address office@bethelexc.com <br /> DEQ License# 36198 CCB# 44551 <br /> GAFORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />