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2 CO S-021 H2)-4r <br /> MARION COUNTY PUBLIC WORKS 11'; E " L [ v E <br /> e� BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE - SEP 2 8 2023 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> http://ww .co.marion.or.us/PW/Buildinglnspection UII_DING INSPECTION <br /> w <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, ioh el J G. 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 /> 9 ot)tP 5 Avfne/c Ole 972 7 <br /> Property Situs or Street Address <br /> Described in the records of MARION Countyn as: <br /> Legal Description 7 h Rd(bV1 WT ' Tax Lot#(s)C 93 Cud Ic O <br /> Subdivision, Land Block- <br /> O <br /> PROPERTY OWNER: <br /> Printed Name: ,0 v'1,-05-) <br /> Signature: �� - �Date: - 2/ -- 2(JC�,3 <br /> Address: 7 7 C N ! , Akto(�/Pfione: <br /> City, State, Zip h,e4 v a/V. 9 7 3 Fax: <br /> E-mail Address 5d7C, hP c.'w-5 V6�</ Ce/�' <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Lee Bethel <br /> Company Name: Bethel Excavating <br /> Signature: S7el e( 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 /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />