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r <br /> f ..,, MARION COUNTY PUBLIC WORKS <br /> '''� * "",m,. BUILDING INSPECTION DIVISION <br /> ' ,-::—i —1--���== 5155 Silverton Rd NE E <br /> ii Salem OR 97305 - <br /> CEOVED <br /> (503)588-5147 Fax(503)588-7948 <br /> http://www.co.Marion.ores/PWBuildinp,InspectionJUL 27 ?E1 <br /> MARION COUNTY <br /> NOTICE AUTHORIZING REPRESENTATIVE BUILDING INSPECTION <br /> II <br /> -� -t\0v ,have authorized <br /> _. I t 1ei <br /> I <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 /> 30(0 tMpni kor PO. . 8itvovf n OR 973P1 . <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> Legal Description c i lL a/4;114 best /L Tax Lot#(s) 51 l 533 <br /> PROPERTY OWNER: <br /> Printed Name: I OV l k-GhC�-�l <br /> -riot` u U` l Date: �o "1'.Z3 <br /> Signature: l� — I <br /> Address: o 6 golAl ktv Q-0 - Phone: 503 6141 °I,g&g <br /> City,State,Zip SiWGv1-tm . () 023?3 1 Fax: <br /> E-mail Address l 33(o 0 V-oriMr .l• Cwv'' <br /> AUTHORIZED_REPRESENTATIVE: <br /> Printed Name:_ • __ __ •Lz.. ( 4 <br /> Company Name: Bethel Excavating <br /> Signature: 341.— .c. 1 el 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.com <br /> DEQ License# 36198 CCB# 44551 <br /> G:IFORMS1SEFTIC1S-07 Auth to Apply.doc <br /> l <br /> MCS-07 Rev 03/10 4 <br /> SEPTIC <br /> 1 <br /> i <br />