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t`��{ . <br /> MARION COUNTY PUBLIC WORKS <br /> ��� 1j����� BUILDING INSPECTION DIVISION <br /> no- --, - ,. . <br /> ��1 �� 5155 Silverton Rd NE RECEIVED <br /> ` Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 APR 0 2 2024 <br /> http://www.co.marion.or.us/PW/BuildingInspection <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> I, V /42\11 A -Vac U IMe have authorized <br /> �l (Property Owner/Print Name) <br /> I-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 /> �1 C\ L J ( N E 3(X\UK\ <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision,Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: V rt U.r I a 0(n WI(2, <br /> Signature: Vt"-N._ _ ---- Date: 04-.4.aq <br /> Address: Gel (v2hd 1 r\IF Phone: (503) ef4—g1 2 <br /> City, State,Zip 3 cr Lem / og q-1-317 Fax: <br /> E-mail Address V(,l J Lc 2,3 q yjm ai/. Corn <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Jae-Bethel \Lr ?`IBC W'JVV•Ir <br /> Company a e: Bethel Excavating <br /> Signature: Date: L Z 7 <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 />