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- 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/PW/Buildinglnspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> t I, e i'yw oyi LY 'a..vt Ay-a. •M oy1\ p'j a ,have authorized <br /> I' (Property Owner/Print Name) <br /> Katie Ryan. to act as nay agent in performing the <br /> (Authorize ,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 /> 115L k:•ereSta q '311 <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description p,'() Via}$ --OoS c2. Tax Lot 11(s)_a.4( ,\AI 3 IC OldOt <br /> PROPERTY OWNER: ` I <br /> T : Printed Name: 1ceYlYlU CLVICI CONEc\ria Movr6i <br /> Signature: N C td\L J Date: f <br /> Address: 5-1 Lk ai -3 a -eS E Phone: <br /> City,State,Zip Tor Yl X O R •q.7 3 41. Fax: <br /> E-mail Address \<a nASYYlD Yt*\t A ,q M et_I l , COM <br /> — U <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Katie Ryan <br /> Company Na 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 officena.bethelexc.com <br /> DEQ License# 36198 CCB# 44551 <br /> G:IFORMSISEPTICIS-07 Auth to Apply.doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />